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12-101958
Cm.mW.& Federal Way COMMUNITY DEVELOPMENT SERVICES 253 - 835 -2607• FAX 253 - 835 -2609 www.cittioffederalwati.com 0 PERMIT APPLICATION I2_IO(�SS MF CO ME PL DE EN RECEIVED SITE ADDRESS 8 # 1.2 14 5 332ND 57. FEDERAL WPB\i mat 8003 11TY OF FEDERAL WAY PROJECT VALUATION ZONING ASSESSOR'S TAR /PARCEL # t15o ®v TYPE OF PERMIT ❑ BUILDING ❑ PLUMBING ❑ MECHANICAL ❑ DEMOLITION ❑ ENGINEERING FIRE PREVENTION NAME OF PROJECT (Tenant Name /Homeoumer Last Name) F w R 5 CE A, T P- A L I /' ,.T. G V\ S `' l v 1� D S 1 Cs- N .S U. \/q ET ANb D F 1" S P AM K PROJECT DESCRIPTION Detailed description of work to s S ' jt� P o T SEC - NE" O V 1 L-b 1 N E - be included on this permit only NAME PRIMARY PHONE PROPERTY OWNER MAILING ADDRESS E-MAIL CITY STATE ZIP NAM F t 1Z E S To P C O M M N L-�C ONE 410 -719 _0 60 MAILING ADDRESS 6 S T S T 5 P. 2 MAIL G® ` v/ e sto Ce . c CONTRACTOR CUT V NLaVVEP— STATE WA, ZIP 186.6 36a -718 -8603 WA STATE CONTRACTOR'S LICENSE # F(RE5GL 92-20 )j EXPIRATION DATE X30 /1-012 FEDERAL WAY SUSINFSS LICENSE # NAME SAME As MovC PHONE WAILING ADDRESS E -MAIL APPLICANT CITY STATE ZIP FAX PROJECT CONTACT NAME LE C. S A K G fL' NE 7 60 '118 ^g (o D + (The individual to receive and MAILING ADDRESS j S P -L- .' S T. ( E'MAM q fit co respond to all correspondence concerning this application) CITY VANtovEiZ STATE WA, ZIP °19663 FAX 36-a 7t8-8bo3 ALTERNATE CONTACT NAME: 06 rZE£N rPHONZ 360 -719 -9Ga4 E-MAIL beb, "e -Pi@P rests PROJECT FINANCING NAME OWNER-FINANCED Required value of $5,000 or more (RCW 19.27.095) MAILINO 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 cerft that to the best of my knowledge, the information submitted in support of this permit application is true and correct. I certM 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 lincluding costs, expenses, and attarneys' fees incurred in the investigation and defense of such claim), which may be made by any person, including the undersigned, and jiled 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 imlformation supplied to the city as a part of this application. / k SIGNATURE: A� - -,,--- DATE PRINT NAME: ©P� R T D, GiLE E N Del 0. I