11-102019Federal ay tta+tt� ECEIVEiPERMIT Si l�F
COMMUNITY DEVELOPMENT SERV1chYFj I is p p L I CATI O N
253- 835 -2607• FAX 253- 835 -2609
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CITY OF FEDERAL WAY
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CO ME PL DE EN FP .
SITE ADDRESS -
SUITE /UNIT N *A
1'10 r 5 .32 2 Y, d pL r
PROJECT VALUATION
ZONING
ASSESSOR'S TAR /PARCEL N
e
TYPE OF PERMIT
❑ BUILDING ❑ PLUMBING ❑ MECHANICAL
❑ DEMOLITION ❑ ENGINEERING FIRE PREVENTION
NAME OF PROJECT
(tenant Name /Homeoumer Last Name)
p a ke Y a y 134Y
PROJECT DESCRIPTION
! -V% s
Detailed description of work to
be included on this permit only
NAME
PRIMARY PHONE
PROPERTY OWNER
.eaty 04.. )K
MAILING ADDRESS
E -MAIL
'" N -
CITY
C//
edave c'!1'
STATE
u�
ZIP
L r 2
NAME
ra.,.k - t
PHONE
rZ a- 22 2 Y5
MAILING ADDRESS
/en S<
E -MAIL
CONTRACTOR
CITY
STATE
ZIP
FAX
le el
hf.,if
N
WA STATE CONTRACTOR'S LICENSE M
EXPIRATION DATE
FEDERAL WAY BUSINESS LICENSE M
'? & F= 2 e' e.
NAME
PHONE
MAILING ADDRESS
E -MAIL
APPLICANT
CITY
STATE
ZIP
FAX
PROJECT CONTACT
(The individual to receive and
respond to all correspondence
NAME
i
}/
PHONE
MAILIN(}�AUD�tES$�^ ,�
`�
Ili'
E -MAIL
concerning this application)
✓(�/t C
CITY
STATE
ZIP
FAX
ALTERNATE CONTACT NAME:
PHONE
E -MAIL
PROJECT FINANCING
NAME
OWNER - FINANCED
Required value of $5,000 or more
(RCW 19270951
MAILING ADDRESS, CITY, STATE, ZIP
PHONE
I certify under penalty of perjury that I am the property owner or authorized agent of the property oumer. 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///apart of this application.
SIGNATURE: • /y L/✓ DATE -'-5' ' 2_29 • r
1
PRINT NAME: /avt k d t-� 'Cl
Bulletin #100— January 1, 2011 Page I of 3 k:lHandouts\Pelrllit Application