12-100304My or
Federal Way
COMAffiNITY DEVELOPMENT SERVICES
253 -835 -2607• FAX 253 -835 -2609
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*ERMIT S CIF CO ME PL DE E FP
APPLICATI%0 "V_ ED
IAN `,, 4
TE ADDRESS
- � 1',"ACITY OF FEDERAL WA4
SUITE /UNIT #
PROJECT VALUATION
ZONING
ASSESSOR'S TAX /PARCEL # CDS
v
TYPE OF PERMIT
❑ BUILDING ❑ PLUMBING ❑ MECHANICAL
❑ DEMOLITION ❑ ENGINEERING ❑ FIRE PREVENTION
NAME OF PROJECT
(Tenant Name /Homeowner Last Name)
F
PROJECT DESCRIPTION
v\
Detailed description of work to
be included on this permit only
PROPERTY OWNER
NAME C71
P
PRIMARY PHONE
MAILING ADDRESS
E -MAIL
CITY
STATE
ZIP
NAME
PHONE
MAILING ADDRESS ,*�
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E -MAIL
CITYJ,,,,^.�,t
S�'T��AjT`E
ZIP�j -%y/ /
FAX
�ONTRACTOR
WA STATE CONTRACTOR'S LICENSE #
EXPIRATION DATE
FEDERAL WAY BUSINESS LICENSE #
NAME
PHONE
APPLICANT
MAILING ADDRESS
E -MAIL
CITY
STATE
ZIP
FAX
PROJECT CONTACT
(The individual to receive and
AME ?
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HONE _ _
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MAILING ADDRESS
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E -MAIL
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respond to all correspondence
concerning this application)
CITY
STATE
ZIP
FAX
ALTERNATE CONTACT NAME-
PHONE
E -MAIL
PROJECT FI CING
OWNER - FINANCED
Required value o $5,000 or more
MAILING ADDRESS, CITY, STATE, ZIP
PHONE
(RCW 7 0.27.095)
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 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: DATE
NAME:
,,,9_ulletin'4 100 - January 1, 2011 Page I of 3 k: l- landouts \Permit Application
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