12-102660d RECEISD
A PERMIT
Feeral Way JUN 12 2012
CO253- 835 -2607 ELOPMENf SERNCES
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CDS
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SF MF CO ME PL DE EN FP
SITE ADDRESS
SUITE /UNIT 0
PR VALUATION
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ASSESS TAB - O
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TYPE OF PERMIT
❑ BUILDING ❑ PLUMBING ❑ MECHANICAL
❑ DEMOLITION ❑ ENGINEERING FIRE PREVENTION
NAME OF PROJECT
1Tenant Name /Homeowner Last Name)
_
1
PROJECT DESCRIPTION
Detailed description of uaork to
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be included on this permit only
NAME
PRIMARY PHONE
PROPERTY OWNER
1-77 � r- 41A
MAILING ADDRESS
E-MAIL
CITY
STATE
ZIP
NAME %i4 ? i /2 /a.�. o - S��Z"�' / ..� z
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MAD.I � NG ADDRESS 2013
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E-MAII.
CO R
CITY
STATE
ZIP C�
FAX
WA STATE CO OR'S LICENSE •
I T �o o-s'
ESPIRATION DATE
/ /
FEDERAL. WAY BUSINESS LICENSE •
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NAME /+
I— Alty"aJily-
PHONE
APPLICANT
MAILING ADDRESS
E -MAIL
CITY
STATE
ZIP
FAX
PROJECT CONTACT
ahe LrObidual to receive and
respond to all Correspondence
concerning this appltca fonl
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PHONE
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MAILING ADDRESS
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CITY
STATE
ZIP
FAX
ALTERNATE CONTACT NAME:
PHONE
E -MAIL
PROJECT FINANCING
Required value of $5.000 or more
(RCW 19.27. 095)
NAME
OWNER - FINANCED
MAILING ADDRESS. CITY, STATE, ZIP
PHONE
I certVj under penalty of perjury that I am the property owner or authorized agent of the property owner. I certify that to the best
of my knowledge, the information submitted in support of this permit application is true and correct. I certify that I will comply with
all applicable City of Federal Way regulations pertaining to the work authorized by the issuance of a permit. I understand that the
Issuance of this permit does not remove the owner's responsibility for compliance with local, state, or federal laws regulating
construction or environmental laws.
I further agree to hold harmless the City of Federal Way as to any claim (including costs, expenses, and attorneys' fees incurred in
the investigation and defense of such claim), which may be made by any person, including the undersigned, and filed against the city,
but only where such claim arises out of the reliance of the city, including its officers and employees, upon the accuracy of the
information supplied to the city as a part of this application. /
SIGNATURE: • < "" `" rl tiorl/l �l DATE ` d�--
PRINT NAME:
Bulletin #100 - January 1, 2011 Page 1 of 3 k:\Handouts\Pemlit Application
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