10-102937IP
V - / O /
Fl� � PERMIT REC
E PL DE EN FP
crown r52D DEVELOPMENT N SERVICES APPLICATION
JUL 1'2 2010
CITY OF FEDERAL WAY
SITE ADDRESS SUITE/UNIT 0
3& o f �S�- Au SL ( : LL CDI
ROJECT VALUASION, ZONING ASSESSOR'S TAX/PARCEL 0
9'-5/000 --'
$ 2, 0 2., t o A- - et 0 1 3
TYPE OF PERMIT ❑BUILDING ❑ PLUMBING ❑l MECHANICAL
❑ DEMOLITION ❑ ENGINEERING f PREVENTION
NAME OF PROJECT 1 /�' 1 I o �/
(Tenant Name/Homeowner Last Name) ` �w �- WI.11,'�. < ,e8.0 L_,
PROJECT DESCRIPTION . .e " -, - €K-- LAS I i '74 N Imo- Llg�1a
Detailed description of work to �- eg� --p 'C-",yLC 7 -(t. ' t,eve_- Vn [e le__
be included on this permit only tg cast-0.€0-4-- 6/1/10 ,
t ."----i n c_iiik-v‘l r-p.N PRIMARY PHONE �a
PROPERTY OWNER )��C.... W l,�Q7L■L C ,e0L.�c 21j .9'54 ,5 t 5j
Io5SS143 E-MAIL
-e yv`At-. Tt L ZIP Gt>oo 3
NAME ,. rr /� PHONE
4be �'C vi--1)1 v-fl , Ii,c, 2.13 ,12-2,b61S- t).+"7`
A, MAILING ADDRESS F /�,� E-MAIL •
CONTRACTOR 13(- �� r"'t'- e....-4.4.01--rt '
CITY SCAT ZIP FAX
WA STATE CONTRACTOR'S LICENSE 0 EXPIRATION DATE FEDERAL WAY BUSINESS LICENSE•
C)0e-ti 16-c--1.-2-PA t�T[�. '�� 3 /e26.17._. - c 1 - (ootz/b-to-Rc_
N� k4 I A Ceiii , l r-.,C 1 PHOIIFy 3 ` ' ZZ . b8(`,�-
APPLICANT MAILING ADDRESS E-MAIL
L-)7 r1- +1 4-v 6 Dirvt
CITY t
STATE ZIP 4 FAX n> A 22 .6 Be
PROJECT CONTACT NAME --1-- 1.49 lLele (J PHONE R
(The individual to receive and
respond to all correspondence MAD.DI°ADDRESS E-MAIL
concerning this application) ')1"1- C$ 4-wk-C
CITY STATE ZIP FAX
ALTERNATE CONTACT NAME: PHONE E-MAIL
PROJECT FINANCING NAME
/�(_ _‘ El OWNER-FINANCED
Required value of$5 000 or more 1`�Y�
(RCW 19.27.095) MAILING ADDRESS,CITY,STATE,ZIP PHONE
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.
Ifurther 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 a part of this application.
SIGNATURE: DATE I Z Cti Zo!b
PRINT NAME: cT2� tUJ4 - _
Bulletin#100-April 14,2010 Page 1 of 3 k:\Handouts\Permit Application