12-104677CITY OF 4A * PERMIT
Federal RECEIVED
COMMUNITY DEVEWPMENT SERVICES APPLICATION
253 -835 -2607• FAX 253- X09 A
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MF CO ME PL DE EN FP
M Q_ F FEDERAL WAY SITE ADDRESS
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SUITE /UNIT #
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PROJECT VALUATION
ZONING
ASSESSOR'S TAX /PARCEL #
"7 2 2 4 D
$ tD �1 (�
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❑ BUILDING ❑ PLUMBING ❑ MECHANICAL
TYPE OF PERMIT
❑ DEMOLITION ❑ ENGINEERING XFIRE PREVENTION
NAME OF PROJECT
(Tenant Name /Homeoumer Last Name)
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PROJECT DESCRIPTION
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Detailed description of work to
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be included on this permit only
NAME
4,677177 - q
PROPERTY OWNER
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E-MAIL
E.MA
CiT7S
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STATE
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PHONE 1
ING AD , q
EMAIL
CONTRACTOR
T
STAT �
ZIP 9 �
F
WA STATE CO RACTOR'S LICENSE #,
jEXPIRATION DATES
FEDERAL WAY BUSINESS LICENSE
9 M
PHONE
MAILING ADDRESS
E-MAIL
APPLICANT
CITY
STATE
ZIP
FAX
PROJECT CONTACT
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PHONE
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(The individual to receive and
respond to all correspondence
Cr ADDREIS�S
Y ° i% L�
E-MAIL
concerning this application)
CITY
zF1
ERNAT CONTACT
PROJECT FINANCING
NAME J(i D
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 c:erti& 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
by any including the undersigned, and filed against the city,
the investigation and defense of such claim), which ma a made person,
but only where such cl out of the relic of the city, including its offlOers and employees, upon the accuracy of the
igfor►nation supplied t the ci art of this ication.
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SIGNATURE:
PRINT NAME:
Bulletin #100 -January 1, 2011 Page 1 of 3 k:f-ianaouts\remut Application
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