11-103136un CW 'A
Federal Way
COMMUNITY DEVELOPMENT SERVICES
253- 835 -2607• FAX 253- 835 -2609
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• PERMIT O MF CO ME PL DE EN OP
APPLICATION RECEIVED
AUG' 0 12i.4
SITE ADDRESS]
M EIVIAY
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PROJECT VALUATION
$
ZONING
AS SESSOR'S TAX/PARCEL #
0 0 5 0_ 0 0 2 C�
1 v6� �
1 5
TYPE OF PERMIT
❑ BUILDING ❑ PLUMBING ❑ MECHANICAL
❑ DEMOLITION ❑ ENGINEERING XXIRE PREVENTION
NAME OF PROJECT
(Tenant Name /Homeoumer Last Name)
1
S✓ R J C. GCS e w-
PROJECT DESCRIPTION
Detailed description of work to
l
be included on this permit only
PROPERTY OWNER
NAME
- L N C
PRIMARY PHONE
3 0 O
MAILING ADDRESS
E-MAIL
5 0 e—,r L
CITY /
e A !2
TATS ZIP
NAME
y^ \
Y t i�`� �♦ `'L'_��l �/� C.
PHONE
� �� U� { —Wi
ADDRESS `) �
1�
OMAILING
CONTRACTOR
CITY /
�� r '-� [Lf ��J
STA E
ZIP 2 ''r
FAX
WA STATE C JN� RACTOR'S LICENSE # (
ERPD2ATION DATE
FEDERAL WAY BUSINESS LICENSE #
NAME
S Pt (V\ e__
PHONE
APPLICANT
MAILING ADDRESS
E-MAIL
CITY
STATE I
ZIP
FAX
PROJECT CONTACT
NAME (� �Ya r�
PHONE
(The individual to receive and
I `U (�
MAILING ADDRESS n
0 l lA
E -MAIL
respond to all correspondence
concerning this application)
CITY
(/`�
ANTE
ZIP n U cJC_J�.J
FAX
ALTERNAVE TA NAME:
PHONE
E -MALT.
t /VC o
, -n 1 - {0b3
eIst,vv
PROJECT FINANCING
NAME
❑ OWNER- FINANCED
Required value of $5,000 or more
(RCW 19.27.095)
MAILING ADDRESS, CITY, STATE, ZIP
PHONE
I certify 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 th city as a part of this application.
DATE U '� _7 L
SIGNATURE:
PRINT NAME: 0 ^� l ✓
Bulletin #100 - January 1, 2011 Page 1 of 3 k:\Handouts\Permit Application
6 X,�