11-104554•
�mor RECEIVED PERMIT
Federal Way
COMMUN17YDEVELDPMENTSERVICENOv 14 APPLICATION
253 - 835-2607• FAX 253 - 835 -2609
www.diuoffederalwauxoniCITy OF FEDERAL WAY
CD5
SF MF CO ME PL DE E FP
SITE ADDRESS
SUITEMNIT #
5 . 33 2N D SZ". FEDC-(?-AL- WA.,
PROJECT VALUATION
00
ZONING
ASSESSOR'S TAX /PARCEL # Q
J_
TYPE OF PERMIT
❑ BUILDING ❑ PLUMBING ❑ MECHANICAL
❑ DEMOLITION ❑ ENGINEERING FIRE PREVENTION
NAME OF PROJECT
FE0E2A,_ 0 AY .5c.H OO i-S
(TenantName/Homeowner Last Name)
nPva—r cC N rG/
G3
1 'L'"
I A) S A J 5 "i- & A c (gyp rJ (Z102- fit S µPPR ES S /O�
PROJECT DESCRIPTION
Detailed description of work to
Sy 5 *rE M /N -v k f TCH C Af A16 C AOOO To 300
$PFGr F r GA T`t unf 5 .
be included on this permit only
NAME ' • '
PROAARY PHONE
PROPERTY OWNER
I�J/A`//
MAILING ADDRESS
E -MAIL
CITY
STATE
ZIP
NAME T /V O O� S �.d
PHONE
.7&& • 09 o
MAILING ADDRESS C
6100 fZrj4 ✓0- u� p .
E-MAIL
0,4 r- tifood•
CONTRACTOR
CITY��� E
8Tw Ar
p p�
I T/ 0 8
FZC% • 7&7- Z& a
WA STATE CONTRACTOR'S LICENSE #
EXPIRATION DATE
FEDERAL WAY BUSINESS LICENSE #
R.Tyoojm,- D c._
/ 2• / / / l
NAME
RT #*o * mq- SE/1v /DES rAIC.
PHONE
206?- 7Z-& O N0
MADING ADDRESS
6/00 /L�"� J�•�6'^/Gt,+F- S•
E-MAIL
scClln'
APPLICANT
(CON -MA C- T1De.)
CITY
:5 c-,+
S T
ZIP ?J.6
7 �ebl
2-& ' 091 if U
PROJECT CONTACT
NAME �A
'. J!-t 5 � � �'
PHONE
Zd 6. 71-6 ' 0 Lt O
O'he individual to receive and
MAD.ING ADDRESS
6foo fz-' G
E -MAD.
J-RAncb 6t& r7%0oc1 •Cw
respond to all correspondence
concerning this application)
CITY
SE,�f E
STATE
VJ'+
ZIP
`1 og
FAX
2010-7 (,7. 2-te07
ALTERNATE CONTACT NAME:
/C/f irtlTff
PHONE
70&- -724 09t%C)
E -MAIL,
Ircfigr� /7llop
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 certify that to the best
of my knowledge, the irtformation 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
Wormation supplied to the city as a part 4f this applicatio .
SIGNATURE: DATE / %
PRINT NAME: A `( 5ci4 N'S $ Ly
Bulletin #100 - January 1, 2011 Page 1 of 3 k:\Handouts\Permit Application