12-100776CITY OF �� �. MIT
Federal Way
COMMUNITY VELOPM SERVICES
253- 835 -260 7• FAX 253-8 35 -2609 p LI CAT I O N
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SF MF CO ME PL DE E FP
SITE ADDRESS c
1
SUITE /UNIT #
PROJECT VALUATION
C'x
ZONING
ASSESSOR'S TAX/PARCEL #
TYPE OF PERMIT
❑ BUILDING ❑ PLUMBING ❑ MECHANICAL
❑ DEMOLITION ❑ ENGINEERING FIRE PREVENTION
NAME OF PROJECT
1Tenant Name /Homeowner Last Name)
PROJECT DESCRIPTION
C�`e -5 n
o
Detailed description of work to
be included on this permit only
PROPERTY OWNER
NAME V e
J
PRIORY PH _
MAILING ADDRESS
lob
E-MAIL
7M\
S AT
ZIP
NAME 1 �11 -6 (
O 4 _ �I
MAILING
�{ 19\ S
E-MAIL E -MA
CONTRACTOR
gADDRESS
FAX W b
STATE CONTRACTOR'S � SSE #
11=`ip
EXPIRATION / ��
EX
� WAY BUSINESS LICENSE #
oiJ�L
NAM V ,.. 1C_._ V NA
PRONE
ILAP - U
MAJUNG ADDRE" �r ,
�/
E-MAIL
APPLICANT
STATE
ZIP
aCbl-4,y
FAX
2JS
PROJECT CONTACT
(The individual to receive and
NAME �� -J C�Q
--
PHO
MAILING ADD RFp� \ /
\J
E-MAIL
respond to all correspondence
concerning this application)
C
STATE
�
ZIP e \�L4"4
V
FAX
ALTERNATE CONTACT NAME:
PHONE
E -MAD,
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 (r4 formation 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.
1 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.
` II
SIGNATURE: DATE ` 12
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Bulletin #100 — January 1, 2011 l Page 1 of 3 k:\Handouts\Permit Application