11-102769 . _ 1 o z 7 (0 ct
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Federal Way RMIT RECEIVED EIV D EN m
COMMUNITY DEVELOPMENT SERVICES APPLICATION
253-835-2.17•FAX 2 3-835-260• JUL 'f
w,.w.cit 03 JU 1 2 2011
ON
SITE •b' CITY OF FEDE1 tITWAY
1900 6W c=aM?us 2 3L-1X #2- k-Oi-1AL-WAy I OA 9,g0 2-3 CDDL .4 Z
PROJECT VALUATION ZONING ASSESSOR'S TAR/PARCEL#GiCt
ii 100. � - — / 3 2 / a 3 - 9 / 0 3
TYPE OF PERMIT ❑BUILDING ❑ PLUMBING ❑ MECHANICAL
❑ DEMOLITION ❑ ENGINEERING )eFIRE PREVENTION
NAME OF PROJECT
(Tenant Name/Homeowner Last Name) ...• d 1F..- 1 t'
Froliginiz e y F►jzfr_ ALA2m 1-‘voTg_e I PAIv)L REPLAtielielan
PROJECT DESCRIPTION
Detailed description of work to
be included on this permit only
NAME PRIMARY PHONE
PROPERTY OWNER 645e4bE 21 W(_ 253-641-74Y91/
MAILING ADDRESS E-MAIL
CITY STATE ZIP
6-i3 2 ' L bAi ' All/1023
Q�
NAME�GADD oS i t�1G. 2,.sio-5"75"-d31I
MAILING ADDRESS I E-MAIL
/CONTRACTOR /07 (i(�4 H, is 7IV BLVD D. NeLsa'1/1-�dog. °P-6-
CI STATE ZIP FAX
LG,eiJi- 1
lAl A 98C, / 253-73S-y9 74
WA STATE CONTRACTOR'S LICENSE# EXPIRATION DATE FEDERAL WAY BUSINESS LICENSE#
F/ ,4`o1WJ .S /l6 / fZ zo-sot-ro2Spyol3-15E_
NAME -. PHONE
F;g F4"eAbil 1 , x. Za(o- f5 5� -031/
APPLICANT MAILING ADDRESS E-MAIL
/er-? tel/4SOM)A7aA /&i-Vb..
CITY STATE ZIP FAX
{411Zoe•//F' 1A44- 9Boa/ 253 -73S-1/976
PROJECT CONTACT
NAME �,'� PHONE
(The individual to receive and EvA^J I�-y b I N S 2cL, °575- a 3 1 /
respond to all correspondence
MAILING ADDRESS E-MAIL 7 E-MAIL
concerning this application) I e7�Q 6II►AJC.TQt) 13 Lv b
CITY STATE ZIP FAX
ALG,o,J/4 WR 9S0®1 253-73s--VT 71&
ALTERNATE CONTACT NAME: PHONE E-MAIL
/.)rz;LS 0,/204/C 206-575-03 l)
PROJECT FINANCING NAME
` ' ,/� OWNER-FINANCED
0
Required value of$5,000 or more /v T
(RCW 19.27.095) MAILING ADD ,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.
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 -7- — //yioa,,We'//e-----"------
PRINT NAME: 2 6'u'T/yl/2aGl/e
Bulletin#100—January 1,2011 Page 1 of 3 k:\Handouts\Permit Application