12-102112RE�
CITY OF A FA RMIT
Federal Way MAY 14
CO2 3 83 607• FL - 5 610ES 'P LI CATI O N
www.cttuoftederalwauxom F FEDERAL wAY
CD
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SF MF CO ME PL DE EN FP
APPROVED lie)
SITE ADDRESS
3 3Y{44:7
SUITE /UNIT#
22d =Z
PROJECT VALUATION
$ ,
ZONING
ASSESSOR'S TAR /PARCEL #
I t- � / O
TYPE OF PERMT
❑ BUILDING ❑ PLUMBING ❑ MECHANICAL
❑ DEMOLITION ❑ ENGINEERING FIRE PREVENTION
NAME OF PROJECT
(Tenant Name /Homeowner Last Name)
�Q {' ( / ; /� �/
PROJECT DESCRIPTION
Detailed description of work to
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X
be included on this permit only
NAME
PRIMARY PHONE
PROPERTY OWNER
MAILING AffDRMS
E-MAH.
CITY
STATE
ZIP
NAME �1� /
�!
PHONE
MAILING ADDRESS
rr-&
E-MA[L
CONTRACTOR
CI S
ZIP
FAX
TATE CONTRA OR'S LICENSE #
r
EXPIRATION DATE
/i
FEDERAL WAY BUSINESS LI ENSE #
NAME
PHONE
MAILING ADDRESS
E-MAIL
APPLICANT
CITY
STATE
ZIP
FAX
PROJECT CONTACT
NAME
PHONE
(The individual to receive and
respond to all correspondence
MAILING ADDRESS
E -MAIL
concerning this application)
CITY
ST TE
ZIP
FAX
ALTERNATE CONTACT NAME:
PHONE
E -MAIL
PROJECT FINANCING
N
OWNER - FINANCED
Required value of $5,000 or more
(RCW 19.27.095)
ING ADDRESS, CITY, STATE, ZIP
PHONE
I certify under penalty of perjury t 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, andJled 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 a par this application.
SIGNATURE: DATE S_
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PRINT NAME: `� [i/ /1 �i
Bulletin #100 —January 1, 2011 Page 1 of 3 k:\Handouts\Permit Application
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