12-104248cm or
Federal Way
RECEIVEOpERMIT
COMMUNITY DEVFLOPME8 SERVIC
253 - 835 -2607EAX 253N35 -2609 ES S C p 17 APPLICATION
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CI'n OF FEDERAL WAY
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iMF CO ME PL DE EN FP
SITE ADDRESS
SUITE /UNIT X
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ROJECT VALUATION
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ASSESSOR'S TAX /PARCEL M
TYPE OF PERMIT
❑ BUILDING ❑ PLUMBING ❑ MECHANICAL
❑ DEMOLITION ❑ ENGINEERING fleFIRE PREVENTION
NAME OF PROJECT
(Tenant Name /Homeowner Last Name)
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PROJECT DESCRIPTION
Detailed description of work to
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be included on this permit only
PROPERTY OWNER
NAME L /
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PIMARY PHONE
MAILING ADDRESS
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CITY
STATE I
ZIP
NAME
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PHONE
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MAILING ADDRESS
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CONTRACTOR
CITY
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STATE
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ZIP
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FAX
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EXPIRATION DATE
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FEDERAL WAY BUSINESS LICENSE M
NAME
PHONE
MAILING ADDRESS
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APPLICANT
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STATE
ZIP
FAX
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PROJECT CONTACT
(The individual to receive and
NAME
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MAILING ADDRESS
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respond to all correspondence
concerning this application)
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ZIP
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ALTERNATE CONTACT NAME:
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PHONE
E -MAIL
. Coo,
PROJECT FINANCING
NAME
R1 OWNER - FINANCED
Required value of $5,000 or more
MAILING ADDRESS, CITY, STATE, ZIP
PHONE
(RCW 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 f sled 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 tof the city as a part of this application.
SIGNATURE: P,) e, DATE d[�t W ZO 12
PRINT NAME: ' e A. mo%
Bulletin #100 - January 1, 2011 Pagel of 3 k:\Handouts\Permit Application