16-102993 REIVED PERMITIIPPLICATION
/eralWay 02015
SUN 2
FIRE -
��(� SWAY
KNIT NUMBER _ (/� `01 A
TARGET DATE
SITE ADDRESS / SUITE/UNIT S
?j 1j// `2 ) S-1- ��� s L1./
PROJECT VALUATION ZONING ASSESSOR'S TAX/PARCEL M
$ 1SS'pi� Zs � / 03 - ? D U ?�.
TYPE OF PERMIT ❑ BUILDING ❑ PLUMBING ❑ MECHANICAL ❑ DEMOLITION ❑ ENGINEERING LIRE PREVENTION
NAME OF PROJECT 1 Y l �,!'�+
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PROJECT DESCRIPTION N V LA) V L. 306 \' Y'' y5, 'v 0/ 7 l� e Cd
Detailed description of work to
be included on this permit only
NADIE PRIMARY PHONE
PROPERTY OWNER 1C-"I. A`. 17�/ - .
MAILING/ADDRESS E-MAIL
re>4 SoV'').3 �t, 1C
CITY `/ 'jSTATE I ZIP
NAME `'^�Q Y� tom-' �) Y�.. ,'I� L- 1 PHONE
MAILING ADDRESS E-MAIL
CONTRACTOR 2�ti!q7 1//c, ,-1 1 A/i- )6:.---
CITY STATEE ZIP / FAX
fL"1 Z I A /X4) 2
WA Ste'`ATE CONTRACTOR'S LICENSE a EXPIRATION DATE FEDERAL WAY BUSINESS LICENSE X
--ranlk- S'? C/.2(-cc) c1_/2L 121:11 r
NAME PRIMARY PHONE
rUi11 - C->00 Y.'i ¶ I
APPLICANT MAILING ADDRESS E-MAIL
cy/q - l/IC' ,i'h /A/1 I, ),---y-4.1i1 g. 'i.,), .-?_/d ii y'
CITY STATE ZIP -FAX
>e erl WO 9)-o-ii-
NAME PRIMARY PHONE
PROJECT CONTACT
(The individual to receive and MAILING ADDRESS E-MAIL
respond to all correspondence
concerning this application) CITY STATE ZIP FAX
PROJECT FINANCING NAME ❑ 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 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 (� ' 2..,,-/6
PRINT NAME: IV.,--0 n i'--
Bulletin#100—January 4,2016 Page 1 of 3 k:\Handouts\Permit Application