13-101097error PERMIT APPLI ?Et
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Detailed description of work to
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be included on this permit only
PROPERTY OWNER
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rMe individual to receive and
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Required value of$5,000 or more
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MAILING ADDRS88, CITY, STATE, ZIP
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t esrt(& under penalty of perjury that I am this property owner or authorised agent gf the property owner. I cwtA& that to the boat
of mg knowtodpa. the Isormatton submitted in support of this permit application is true and correct. 1 cert(fy that r out eompiy with
all applicable City of lWdwW Way regulations pertaintag to the umrk authorised by the iss4 u" of a pwmtt. I undw*wtd that dw
issuance of this permit does not remove the caner's responsibility for compliance uMth 9"al, state, or federal taws regulating
construction or environmental laws.
I further agree to hold harmless the City o! Federal Wag as to any etaim jinoluding east:, expenses, and attorneys' fees incurred in
the investigation and dgf ase of such claim), which may be made by any person, including the undersigned and flied against the eltih
but only where each ctadm arises out of the re8anes of the citj& Including its OBiors and employees, upon the acauraog of the
InOrmation supplied to the city as a part of this application.
SIQNATURE: BATE j (p
PRINT NAME: �V- 01OLh1 CTr
Bulletin #100- January 1, 2013 Page I of k:tHandoutslPermit Application
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