12-100308v D
MY OF �.
Federal PERMIT
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SITE ADDRESS
SUITEMWIT ;
PROJECT VALUATION
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ASSESSOR'S TAX/PARCEL #
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TYPE OF PERMIT
❑ BUH DING ❑ PLUMBING
❑ MECHANICAL
❑ DEMOLITION ❑ ENGINEERING
(FIRE PREVENTION
NAME OF PROJECT
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PROJECT DESCRIPTION
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Detailed description of work to
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be included on this permit only
NAME
PRIMARY PHONE
PROPERTY OWNER
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MAUING ADDRESS
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CITY
STATE
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NAME
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PHONE
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MAnJNG ADDRESS
E-MAIL
CONTRACTOR
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STATE
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ZIP
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FAX
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WA STATE CONTRACTOR'S LICENSE i
E%PIRATION DATE
FEDERAL WAY BDSBCM LICENSE #
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NAME
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PHONE
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APPLICANT
MAnXNG ADDRESS
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CITY
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STATE
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ZIP
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FAX
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PROJECT CONTACT
NAME
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PHONE
r1he individual to receive and
MAUMG ADDRESS
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E-MAH,
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respond to all correspondence
concerning this application)
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.STATE
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ALTERNATE CONTACT NAME:
PHONE
WMAB.
PROJECT FINANCING
NANO
OWNER- FINANCED
Required value of $5,000 or more
MAnMIG ADDRESS, CrrY. Sulks. ZIP
PHONE
(RCW ]9.27.095)
I certify under penalty of perjury that I am the property owner or authorized agent of the property owner. I certtl y 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 taws.
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
information supplied to the city as a part of this ication.
qffcers and employees, u the accuracy of the
SIGNATURE:
DATE 6
PRINT NAME: /
, /
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Bulletin #100 -January 1, 2011 Page 1 of 3 k:\HandoutslPeumit Application
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