12-103783- �.., A eD
Federal A
•PERMIT
COMMUNITYDETLOP NTSERVICES f�O12 APPLICATION
253 - 835 -2607• FAX 253- 835 -2891 (.
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A. NY
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5F MF CO ME PL DE E FP
SITE ADDRESS r,1.1-1 C
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SUITEMNIT #
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AIRP OJECT VALUATION
ZONING
ASSESSOR'S TAB /PARCEL #
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AS D 0
TYPE OF PERMIT
❑ BUILDING ❑ PLUMBING ❑ MECHANICAL
❑ DEMOLITION El ENGINEERING FIRE PREVENTION
NAME OF PROJECT
(Tenant Name /Homeowner
eowner Last Name)
A
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PROJECT DESCRIPTION
Detailed description of work to
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( :&e 1J le—Lc ecs
be included on this permit only
PROPERTY OWNER
NAME
"A P-5c
PRIMARY PHONE
G ADDRESS
0,04, ?,IQ
E-MAIL
CITY f# PTLA Y JD
STATE
alo
NAME
PHONE
7 'i 61— S 4 :
E-MAIL
CONTRACTOR
_"401P4
CITY w rte.
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WA STATE CONTRACTOR'S LICENSE #
EXPIRATION DATE
FEDERAL WAY BUSINESS LICENSE 0
Ct D(L
( �
NAME
�
PHON � 2q zA e4
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MAILING ADDRESS
E-MAIL
APPLICANT
CITY
STATE I
ZIP
FAk
JCA-( d fb t
PROJECT CONTACT
xAME .5 � � � h ® � �
PHONE
(The individual to receive and
MAILING ADDRESS
E -MAIL
respond to all correspondence
concerning this application)
CITY
STATE
ZIP
FAX
ALTERNATE CONTACT NAME:
PHONE
E-MAIL
PROJECT FINANCING
NAME
OWNER - FINANCED
Required value of $5,000 or more
MAILING ADDRESS, CITY, STATE, ZIP
PHONE
IRCW 19.27.095)
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 the city as a part of this application.
Q C
SIGNATURE: � DATE
PRINT NAME: __l _eo> a UU�iG�i.G IV
Bulletin #100 —April 14, 2010 Page 1 of 3 k:\Handouts\Permit Application
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