12-104676r
"'" drab CEIVED PERMIT
Federal VI��
°253=itE,�L°PME S fI 12DIZ APPLICATION
253 -835 -2607• FAX 253 -83 0
wu +w.GtuofiederNurau.c i
CITY OF FEDERAL WAY
4#4& - t0_L -1 L
SF MF CO ME PL DE EN FP
SITE ADDRESS Cus
SUITE /UNIT #
2005 5. 32V -11` Ft&frCd WN, W q,3 c)p3
PROJECT VALUATION
$ 5) 1 �a . Do
ZONING
° m►ercA. at
ASSESSOR'S TAX /PARCEL #
,7 (P Z Z 4 4
TYPE OF PERMIT
❑ BUILDING ❑ PLUMBING ❑ MECHANICAL
❑ DEMOLITION ❑ ENGINEERING FIRE PREVENTION
NAME OF PROJECT
(Tenant Name /Homeowner Last Name)
�-� (% �i } i
PROJECT DESCRIPTION
description to
� a if A {�
Detailed of work
_ U) I ,
be included on this permit only
PROPERTY OWNER
NAME I) ` S n
PRIMARY q 3 • W3
MAILING V� 7' 0
E-MAIL
1l /IV
' V
NAME u6 d - Pt m
0-
M)INDRE _74 �
gy m,
CONTRACTOR
WA STATE CONTRACTOR'S LICENSE #
�
Iv T
EXPIRATION DATE
d i 3U r 1
FEDERAL WAY BUSINESS LICENSE #
-SSZ-
NAME 5� rn ' A. 5 r
PHONE
MAILING ADDRESS
E -MAIL
APPLICANT
CITY
STATE
ZIP
FAX
PROJECT CONTACT
UA Fn- �
- ) , r ,M l (" �
PHONE
�0 le
(The individual to receive and
respond to all correspondence
�_ ADDRESS
9' �"r Y 1
�Y��►✓"0i�
concerning this application)
cI1X
/E�RNATE
s, 'r 4
W
I-S A2-
Z5 3 -V
AL1FT
CONTACT
A/"(VO ' DWC/5
PHONE
WV10, ,00
E -MAIL
I vYW�fi�astPutt'aiArm. ri
PROJECT FINANCING
NAME X 0-
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 authorised 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 authorised 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 apart of this application.
SIGNATURE: pI f��/ DATE 10(( 0((
PRINT NAME: D r e s
Bulletin #100 — January 1, 2011 Page I of 3 k:\landouts\Permit Application