12-102061CITY OF E Vf ERMIT
Federal Way y ((
COMMUNITY DEVELOPMENT SERVIC f�J, y } U � " ; p p LI CAT I O N
253- 835 -2607• FAX 253 -835 -2609
`VWW.`II tMF FEDERAL WAY
mime,
SF MF CO ME PL DE E FP
SITE ADDRESS V 0
SUITE /UNIT #
PROJECT VALUATION
$ &I X. -
ZONING
ASSESSOR'S TAX /PARCEL #
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TYPE OF PERMIT
❑ BUILDING ❑ PLUMBING ❑ MECHANICAL
❑ DEMOLITION ❑ ENGINEERING IRE PREVENTION
NAME OF PROJECT
(Tenant Name /Homeowner Last Name)
PROJECT DESCRIPTION
2
Detailed description of work to
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be included on this permit only
PROPERTY OWNER
N E `
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PRIMARY PHONE
M!AEELIN9 ADDRESS 4&-4 �
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E-MAIL
CITY �r
STATTE ZIP �
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PHONE • ��W
3
MAILING ADDRESS
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CONTRACTOR
CITY
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FAX Abbot 0
FEEDERAL
WA STATE CONTRACTOR'S LICENSE #
EXPIRATION DATE
WAY BUSINESS LICENSE #
9-1 It
tee
NAME �./�1
PHONE • e*.;,�•�
MAIL G ADDRESS
E-MAIL
APPLICANT
CITY �
SE ZIP -7!7 tPjE7
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PROJECT CONTACT
NAME `
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PHONE
2;
(The individual to receive and
MAILING ADDRESS �}�
P" C.,� C�TCf
E -MAIL
i�j'� &47'CEJRL
respond to all correspondence
concerning this application)
C TY
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ZIP �J '✓ `r
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ALTERNATE CONTACT NAME:
PHONE
1 $S3� ll�
E-MAIL
��Fit�u• cu.�t
PROJECT FINANCING
NAME
OWNER - FINANCED
Required value of $5,000 or more
MAILING ADDRESS, CITY, STATE, ZIP
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 claim arises out of the reliance of the city, including its officers and employees, upon the accuracy of the
irtformation supplied to the city as a part of this application.
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SIGNATURE: .4 DATE
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PRINT NAME: I t-7/ r �
FRn �Cn 1 �
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Bulletin #100 - January 1, 2011 Page 1 of 3 k:\Handouts\Permit Application
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