13-104653 20\ oV r
CITY OF.A. PERMIT APPLICATION
Federal Way RECEIVED
PERMIT NUMBER 4— I C) �I ( 53 -Fp OCT 21 2013
_ _ TARGET DATE
CITY OF
� ttDE
RAL WAY
SITE ADDRESS SUITEE/UNICEDS
r tco c N� \ ,ni. ' � :CT-p a\ a)Lui i p V..PME 4 o C 5-9
PROJECT VALUATION I ASSESSOR'S c-
$ r2- \ `3 a \ 0 4 - °t o� �-c-
TYPE OF PERMIT ❑ BUILDING ❑ PLUMBING ❑^MECHANICAL ❑DEMOLITION ❑ ENGINEERING L�7 FIRE PREVENTION
NAME OF PROJECT CA M Et) �[,\J A - /r Q
PROJECT DESCRIPTION p,� �` r
Detailed description of work to �� 1-Q 12_ Q � 1 Q p\c coo-cry-2\
be included on this permit only
NAME PRIMARY PHONE
PROPERTY OWNER t_e `05S-* - l
MAILING ADDRES E-MAIL
V Ci.X,?k/s
STATE ZIP
c QN 1� ( , vJA °CSo
NAM PHONE
MAILING ADDRESS ^ E-MAIL
CONTRACTOR r)4/'�� p-- f� ,` 1
CITY �C.IJ '\ TA ZIP V� FAX
WA STATE CONTRACTOR'S LICENSE# EXPIRATION DATE FEDERAL WAY BUSINESS LICENSE 41
NAME PRIMARY PHONE
Cc. ,-- ..2__Q A c, C0-`\ - .c ∎.(z.0 co
APPLICANT MAILING ADDRESS E-MAIL
CITY STATE ZIP FAX
NAME" PRIMARY PHONE
PROJECT CONTACT `-r_ 1.1..7 C S\rI
(The individual to receive and MAILING ADDRESS ' E-MAIL
respond to all correspondence \1 C c-` v`�/n1i1k.AQ C -
concerning this application) CITY sT�) ZIPckwi FAX
-)n^A�A'U !
NAME
PROJECT FINANCING ❑ 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 a part oof Jth�is application. 1 2
SIGNATURE: ('� I �'1�� '/�/V DATE 0 1 l 15 1 7
PRINT NAME: WI 0
Bulletin#100—January 1,2013 Page 1 of 3 k:\Handouts\Permit Application