12-105343m„m 'A
Federal Way
COMMUNITY DEVELOPMENT SERVICES
253 - 835 -2607• FAX 253 - 835 -2609
ww w. dtuot7ede ralu au. co m
0 A - /053 3
PERMIT SF MF CO ME PL DE E FP
APPLI ENNO1T
NOV 2 6 2012
SITE ADDRESS
SUITE /UNIT #
IIplU S. 3'N "' SY CITY OF FEDERAL WAY
D-S
PROJECT VALUATION
ZONING
ASS&9ffS TAR /PARCEL #
$ 3,1 2.5
Br J BC
�L I '), I L
TYPE OF PERMIT
❑ BUILDING ❑ PLUMBING ❑ MECHANICAL
❑ DEMOLITION ❑ ENGINEERING FIRE PREVENTION
NAME OF PROJECT
tenant Name /Horneowner Last Name)
a AL
Merl+ E Cec-4 lL M r22"„�k s
G
�`� SO �i n l�(f/'' ro,fe cw;b �^ 6¢ (or✓ HG,,✓ I'1 C t t�'^',i. G
PROJECT DESCRIPTION
Detailed description of Mork to
► lG�✓ S ��� k�G/f
be included on this permit only
PROPERTY OWNER
NAME
W. -IlL peel e- 6F SP�kA,� c
PREMLARY PHONE
Saq. s ;,g -393v
MAILING ADDRESS
Po Ro 3 � 8
E-MAE.
CITY
SPoltpY,�
STA
w
ZIP
4KZZO- 9
NAM 1
c ,/
ESln k FI r* - 5�5 °W � 5
Z S ` W— 2,X 5 -/
CONTRACTOR
MAILING ADDRESS
1106 S V' r4 4Ve 6
E-MAII.
3 ot,rt r
CITY
T^,CoV t &
STATE
wA-
ZIP
-N �iZ4
FAX
?_%3 Its 23so
WA STATE CONTRACTOR'S LICENSE #
SM�Tt,I(^S so
EXPIRATION DATE
1Z / 31 /
FEDERAL WAY BUSINESS LICENSE #
10/- i??-06dOSS-oo-l3t-
NAM
o f a e%4 r 4 C� T
PHONE
APPLICANT
MAILING ADDRESS
E MAII
CITY
STATE
ZIP
FAX
PROJECT CONTACT
(The individual to receive and
respond to all correspondence
concerning this application)
NAME /�
Jak^ R�fl•el�i,. r-
7 ��p
2S3
MAILING ADDRESS
l 1 V G S fl` Ae 6-
E-MAIL
Ol. vI (� @S i t4ti<11• r•. towr
CITY 74',C& I- a *
s&1-+
g 9 `� �'�`
Z S� '%� Z 3 5"0
ALTERNATE CONTACT NAME:
Nf 14e v n c✓"
PHONE
ZS 3 �4�8- Z�
E-MAII,
n v rr CAO"
PROJECT FINANCING
NAME
OWNER - FINANCED
Required value of $5.000 or more
(RCW 19.27.095)
MAILING ADDRESS, CITY, STATE, ZIP
PHONE
I eert(fy under penalty of perjury that I am the property owner or authorized agent of the property owner. I certVy 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 a part of this application.
SIGNATURE: DATE
PRINT NAME:
Bulletin #100 —January 1, 2011 Page I of 3 k:\Handouts\Permit Application
• 0
CRITICAL AREAS ON PROPERTY?
WATER PURVEYOR
SEWER PURVEYOR
VALUE OF EXISTING IMPROVEMENTS
1�,v
Ca(4 l.a,i-n W , 4)e
L ,. jU;, vtA JA44 -/
$ 1(61 COO
EXISTING/PREVIOUS USE
LOT SIZE (In Square Feet)
114, R 73
EXISTING FIRE SPR W ELER SYSTEM?
_(Yes L No
PROPOSED FIRE SUPPRESSION SYSTEM?
❑ Yes )(No
Bulletin #100 —January 1, 2011 Page 2 of 3 k:\Handouts\Permit Application