17-100284CITY OF O I&I . PERMIT APPLICATION
.
PERMIT CENTER + 33325 8+h Avenue South + Fe 98003=6325
Federal Way 253- 835 -2607 + FAX 253 - 835 -2609 + permitcente (Tcityoffederalway.com
�
JAN 19 2017
PERMIT NUMBER _ l n 0 Z 8 4 i _` p TARGET DATE
SITE ADDRESS
SUITE /UNIT 0
U, 4-e. l I
VALUATION
ZONING
ASSESSOR'S TAAX /PARRCEL 0
�P%ROJECT
`I / C)y. OC
1 ?L (0— (L 0 -
TYPE OF PERMIT
❑ BUILDING ❑ PLUMBING ❑ MECHANICAL ❑ DEMOLITION ❑ ENGINEERING IRE PREVENTION
NAME OF PROJECT
` C e—
PROJECT DESCRIPTION
Detailed description of work to
be included on this permit only
NAME
PRIMART PHONE
PROPERTY OWNER
MAILING ADDRESS
E-MAIL
CITY
STATE
ZIP
NAME
PHONE
MAILING ADDRESS
E -MAIL
CONTRACTOR
CITY
STATE
ZIP /
FAX
A STATE CONTRACTOR'S LICENSE N
FWV2��
EXPIRATION DATE
Q
FEDERAL WAY BUSINESS LICENSE N
�OU L C
0(q - U Z2 (o54,J6 e tr.
MAILING ADa
1-7 13 IV 4_
E -MAIL
APPLICANT
&4" Q
TATE
SM
ZIP 13
PROJECT CONTACT
NA
N
7A M a AS
PRIMARY PHONE
MAILING ADDRESS
E-MAIL
(The individual to receive and
respond to all correspondence
CI'T'Y
STATE
I ZIP
FAX
concerning this application)
PROJECT FINANCING
NAME
❑ OWNER-FINANCED
When value is $5,000 or more
(RCW 19.27.095)
MAILING ADDRESS, CITY, STATE, ZIP
PHONE
I cer ft under penalty of perjury that I am the property owner or authorised agent of the property owner. I certifli 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 authorised 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 harml ss the City of Federal Way as to any claim (including costs, expenses, and attorneys' fess incurred in
the investigation and defense ch claim), which may be made by any person, including the undersigned, and filed against the city,
but only where such clAdm ea o9l of the reliance of the city, including its qffleers and employees, upon the accuracy of the
information supplied of this application.
SIGNATURE: DATE
PRINT NAME: 1 Q Y JU-
Bulletin #100 —January 29, 2016 Page 1 of 2 k:\HandoutslPermit Application
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