14-105895CITY OF 4,
Federal Way
PERMIT NUMBER (
~ PERMITAPPLICATION
Mavm
1 10 5_F9 15-- PP
NOV 12 2014
TARGET DATE
C11y OF FEDERAL 107.4.1.-
rl r'% r-
SITE ADDRESS
301 So"th 3Z0 t" Strt,et
SUITE #
PROJECT VALUATION
ZONING
ASSESSOR'S TAXIPARCEL #
$ :?G,
7 Z t y- s
TYPE OF PERMIT
/
El BUILDING ❑ PLUMBING El MECHANICAL ❑ DEMOLITION El ENGINEERING L7 FIRE PREVENTION
NAME OF PROJECT
6 per ( blea 1 th Fsd &;-q l Wa.
0d r rC,0"*rw1 To eXrSfWt S rhi lar- s- ftev"
PROJECT DESCRIPTION
Detailed description of work to
rniW c,-,i (il.`>S hll vi Its ao-
be included on this permit only
PROPERTY OWNER
NAME �
`7 u �j1-h WA o
PRIMARY PHONE
2S3 -IF 71-Y -70,00
MAILING ADDRESS 301 S. 320 tti St
E -MAIL
CITY /
S`N E
ZIP
//
ten(
NAME /
Parfrot Px,
PHONE
?S2 -RM_22_g0
MAILING ADDRESS
%� % 7OTAT�E
E-MAIL
v/n.t,nrt n r
CONTRACTOR
CITY
,y^
1 e
STATE
AW,/4
ZIP ""�_ L ��
�/ /�
FAX S1 so
2S3-g2Z-
WA STATE CONTRACTOR'S LICENSE #
P AL-1 F'POgq F
EXPIRATION DATE
10 i 0 t IS
FEDERAL WAY BUSINESS LICENSE #
r9- a1- l0tggp -0,O -BL
NAME
Dal i`.-I �G�•- iS�erl soY,
PRIMARY PHONE
25 3 - q2 - 22 9O
MAILING ADDRESS �1
2-70'7 7 d"► A E
E -MAIL
avTr) zhAwte+'I son Qe
APPLICANT
CITY
Fil
STATE
ZIP
of S- z41
FAX
ZS3- g .Zz'6150
NAME (J--
PRIMARY PHONE
PROJECT CONTACT
ab
MAILING ADDRESS
E -MAIL
(The individual to receive and
respond to all correspondence
CITY
STATE
ZIP
FAX
concerning this application)
PROJECT FINANCING
NAME
E] 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
information supplied to the city as apart of this application.
/
11 11,1 y
�r�
SIGNATURE: DATE
PRINT NAME: L/ awrei
Bulletin #100 -January 1, 2013 Page 1 of 3 k: \Handouts\Permit Application
Tr'iI exo�