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16-103866
... RECED PERM1411 APPLICATION CITY OF PERMIT CENTER+33325 8th Avenue South + Federal Way,WA 98003-6325 Federal Way 4.06 0 9 2016 253-835-2607 + FAX 253-835-2609 +perrniteenter@cityoffederalway.com ,�fl- y OF FEDERAL WAY PERMIT NUMBER j /,• _ L 3 y /_ - P� l�/ V CJ �([ TARGET DATE SITE ADDRESS SUITE/UNIT 4 3 3"" t/S Z/ sf 4 V6 6 A/ PRO) ZONING ASSESSOR'S TAX/PARCEL 4 / O 3 - O $ _Op 0 s'7--) A c ,9,TYPE OF PERMIT ❑ BUILDING ❑ PLUMBING ❑ MECHANICAL ❑ DEMOLITION ❑ ENGINEERINGE PREVENTION NAME OF PROJECT //ohs /C.04. - AirM,-ke% PROJECT DESCRIPTION Detailed description of work to In -714011;14g gA rP e/niu-prt H©0`f �//D Iv //odd. y'f i be included on this permit only / / NAME r/ Walt"a 1, - - _____________________ PROPERTY OWNER MAILING ADDRE YJI_ ,• • if" CITY STATE ZIP .. _ NAME G /'e674-;n c 206-5V-V910 MAIILIING ADDRESS / E-MAIL CONTRACTOR ( v eox 21$i owicylinyoveyetil OQ CO')Y? CITY STATE ZIP'809/ FAX WA STATE C NTRACTOR'S LICENSE• EXPIRATION DATE FEDERAL WAY BUSINESS LICENSE• 0 dee • ■ •1./ i • NAME PRIMARY PHONE Sa.k-e AS Above APPLICANT MAILING ADDRESS CITY STATE ZIP FAX ------- -- --- -- ----- --------.__-.___-.._--- NAME PRIMARY PHONE PROJECT CONTACT /o U"1 eh .)_0(-- em~7 ` 99 a (The individual to receive and MAILING RESS t E-MAIL respond to all correspondence po 4�0 X N$d concerning this application) CITY _� STATE ZIP FAX AV. Y !/// NAME PROJECT FINANCING ❑ OWNER-FINANCED When value is$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 a reliance of the city, including its officers and employees, upon the accuracy of the information supplied to the city as a part f this application. SIGNATURE: / DATE O Q ? — i S PRINT NAME: D 1//\(F1 0 N Bulletin#100-January 29,2016 Page 1 of 2 k:\Handouts\Permit Application