11-1007120
avr or /
FederaRffCEIV ERMIT
COM DEVELOPMENT SERVICES p LI CATI O N
253 -835 -3 -835- 2607• FAX 253 -835 -2609
www dtuofl'ederalwau mmC E ® 2 9 . !
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SITE ADD
12l
SSE /UNIT Y
PROJECT VALUATION
$
ZONING
ESSOR'S TAX /PARCE
�� --
l-4 2 l _ t Z z
TYPE OF PERMIT
❑ BUILDING ❑ PLUMBING ❑ MECHANICAL
❑ DEMOLITION ❑ ENGINEERING FIRE PREVENTION - ilk' l�S �► f l
NAME OF PROJECT
1Tenant Name /Homeowner Last Name)D110
Q
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PROJECT DESCRIPTION
LA
t,�
l� '� p lA S' T19 6� - �� �7j �"�p,G_• ,
Detailed description of work to
be included on this permit only
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h- W- A- V'_1ZL_ , n A � � t W -ca c fry �� D
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PROPERTY OWNER
N vY
��jp �, � � .t�C'� -
i'C� I PHONE >
CS
NWLING ADDRESS
c6� S . 32a 5a�,
E-MAD,
ZIP
N
PHONE ll
MAILING ADDRESS
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/ I
°y °u` e1��,lJ1. (AI"
f,4
ONTRACTOR
CITI
ZIP
FAX V
WA STATE CONTRACTOR'S LICENSE M
JoE VJC. `2 2.T
EXPIRATION DATE
i 12-012,
FEDERAL WAY BUSIN]CSS LICENSE 8
2a- 02-, — 0o82.6 -8a- i
N vow �K4A,
PHGNE
MAILING ADDRESS II
051 " -4}n %ue L6LtT.
U."'
APPLICANT
C
tPe
STATE
I
ZIP
P1 ,,42_,
FAX
'L6>' -IZ2 . 68245
PROJECT CONTACT
NAME �
1 W l
PHONE /
211
(The individual to receive and
respond to all correspondence
MAIL G ADD
E.�,
conceming this application)
���
CITY
ST {
I wl •-/�
zn,
%,42A
FAX
ALTERNATE CONTACT NAME:
PHONE
E -NEAIL
PROJECT FINANCING
NAME
OWNERrFINANCED
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 authorised 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 authorised 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 ckdnib which may be made by any person, including the undersigned, and filled fled 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
igfbrmation supplied to the city as apart of this application.
SIGNATURE: DATE u"� 2Z��
I ' I�
• �P7C1(,(, A-�--k '
PRINT NAME W
Bulletin #100 -April 14, 2010
Page 1 of 3
k:Ulandouts\Permit Application