09-104947et PERMIT
CITY of o r
Federa a V'
COMMUNITY
- DEV Lo
FAX 2 C9 ES
APPLICATION
253 835 -2607
wumatuoffederalwauxom
I
SITEADDRESS 1 ®F r�5 S= r_ejc Q C l
SUITE /UNIT # ZONING ASSESSO 'S TAX /PARCEL #
�'�( I I,- Y) - I CSI -Z _�_ S 0 a
NAME OF PROJECT
(Tenant or Homeowner Name)
❑ BUILDING ❑ PLUMBING ❑ MECHANICAL
TYPE OF PERMIT
❑ DEMOLITION ❑ELECTRICAL ❑ENGINEERING AFIRE PREVENTION
PROJECT DESCRIPTION
Detailed description of work to
be included on this permit only
PROPERTY OWNER
OWNER IS ALSO:
NAME
CONTRACTOR MAILING ADDRESS, CITY. STATE
WA STATE CONTRACTOR'S
R'
CCOONTRACCTOR'S( LICENSE #
E1 / " 6 C.� P A r Lam. 9'� V," L IG
NAME
APPLICANT SCE
MAII DIG ADDRESS. CITY, STATE, ZIP
PROJECT CONTACT
(The individual to receive and
respond to all correspondence
concerning this application)
MAILING ADDRESS, CITY, STATE, Zn?
ALTERNATE CONTACT NAME:
APPLICANT
(O CY)
M
EXPIRATI3ON DATE
C
PHONE
PRIMARY PHONE
E-MAU
PROJECT CONTACT
PRIMARY PHONE
ZO'567
FAX
94�7 - 23 1 Z
FEDERAL WAY BUSINESS LICENSE #
20 7 0(�7--1 G
PRIMARY PHONE
FAX
PRIMARY PHONE
zc 30
FAX
Z-31 Z
E-MAM
PROJECT FINANCING NAME
OWNER - FINANCED
Required for projects with
value of $5,000 or more MAILING ADDRESS, CITY, STATE, ZIP PRIMARY PHONE
(RCW 19.27.095) ( -
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 cl m arises out of the relia of the city, including its officers and employees, upon the accuracy of the
information supplied to the�ty as g pgr;othi"ppl on.
SIGNATURE: DATE
jamj/- 1
PRINT NAME: ��Yi�l
Bulletin #100 - 4/21/2009 Page 1 of 4 k:\HandoutAPernut Application