11-101130� 11
c -col 13 OF
Fed Fi v G1 PERMIT SF MF CO ME PL DE EN FP
COFMUMT 1 PMEN SERVICES
60 .1 A8
APPLICATION
253835 -27 1AX 253 2 4N + l
wunuc N V( R
ccnr-RAL WAY
SITE
6 d4 S. �� 41� e +, '`Y�ti 1Ja1' I,JA q�oo3
6"M
SUITE /UNIT #
PROJECT VALUATION
$ 3, 000.00
ZONING
A38ESSOR' TAX #
5 o 0-
TYPE OF PERMIT
❑ BUILDING ❑ PLUMBING ❑ MECHANICAL
❑ DEMOLITION ❑ ENGINEERING t� FIRE PREVENTION
NAME OF PROJECT
(Tenant Name /Homeowner Last Name)
1
••Y l Ow J o fl e_� ) r 1' ,iZ IQ : U r (,J r
DOW
PROJECT DESCRIPTION
Detailed description of work to
be included on this permit only
04 r W WILA J i 30" phi y1&4 L1 '
A� " QIA►iV\
n- b�j 40 ul
PROPERTY OWNER
NAME
I��W jone$
PRDYAK PRONE
MAILING AD
E-MAIL
CITY
N ITAI
X10 03 to
NAME
rode �, n v►i� ^'!l �UY1 nL
PHONE
5 - 114 - q0a�+
MAILING ADDRESS
1 '- 4 1 -l!
E -MAD,
Q� r0-Comri' ..
CONTRACTOR
�'jV%V%V Q o
2>p X3036- b to
FAX �-►4- �3�-�
WA STATE CONTRACTOR'S LICENSE #
RoT z165�
EXPIRATION DATE
� i�oti
FEDERAL WAT SUGMSSS LICENSE #
' -1059 I-oo -3�.
NAME
PHONE
APPLICANT
MAILING ADDRESS
E-MAIL
CITY
STATE
ZIP
FAX
PROJECT CONTACT
(The individual to receive and
respond to all correspondence
concerning this application)
PLANE
J�'� '^
PHONE 1'
,1T' 9 (Aq exi 116
MAILING AD
I X630 Both 1�e, W
E-MAIL
),t4C, 07 (0
nnuvovcj
STATE
9TA
n50_36- 00i
i+A�`�, -114 6317
ALTERNATE CONTACT NAME:
PHONE
E -MAIL
PROJECT FINANCING
NAME
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 certtN 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.
ll
SIGNATURE: DATE UV a 5` d Q( 1
PRINT NAME:
Bulletin #100 -January 1, 2011 Page 1 of 3 k:\Handouts\Permit Application
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