12-100930 Carr OF I PERMIT SF MF CO ME PL DE E .FP 1
Feder
COMMUM7Y REVEL° M E le NT SERVICES 9 1 APPLI CATI O N
253-835-2607•FAX 253-835-26 G� l 1-
www.cityofferleralwau.cora AI
F ERAL N
SITE ADDRES V OF rii)s SUITE/UNIT#
) 900sto,`LA► i& S D2. F .Dii-2AL- iA,AV , wA '3023 /3L 6,.*3
PROJECT VALUATION ZONING ASSESSOR'S TA%/PARCEL#
$ 3000.Qa i2:-'2- i3 ± 1 - 5' / 0 3
TYPE OF PERMIT ❑BUILDING ❑ PLUMBING ❑ MECHANICAL
❑ DEMOLITION ❑ ENGINEERING XFIRE PREVENTION
NAME OF PROJECT
(Tenant Name/Homeowner Last Name) 69$Gi9t�(L a1 DUI. IT1-
rWWl a_PL,EA j. Fr 2rz ALA�fz�YhV PA NT z t. RE.PL, avt r JT.
PROJECT DESCRIPTION J
Detailed description of work to
be included on this permit only
NAME PRIMARY PHONE
PROPERTY OWNER 615t iz- 12t D6,iZ 26-3-40&1 - 7'191-1
MAILING ADDRESS E-MAIL
/900 61,0. 6AMPlAS bz.
CITY STATE ZIP
FE_DEt2iALuurN v'A 98023
NAME/ /2rz oA)1, /Ai L, 20(0-5"75--031/
MAILING ADDRESS E-MAIL
CONTRACTOR IT1O7 bk)ASN/l'XtTelJ J& tYj3
c l-4L&CPJA sV'JA Z �10c0 1 25- --23S -1-143 NO
WA STATE CONTRACTOR'S LICENSE# EXPIRATION DATE FEDERAL WAY BUSINESS LICENSE#
Flg r*o99/1-W 5- / /lo / /2 20-01-102944-cQ-(3 L-
NAME TvA IJ Z.13( P1/41 S /,-1/2/�aNl_/ L O
�0 , 2c '5 75-c31 I
APPLICANT MAILING ADDRESS E-MAIL
)G7 W JAS1Oir&4.TO/J 3 LU D
CITY STATE ZIP FAX
)9LG.eioA WA 9E3001 253 _.735-'9719
PROJECT CONTACT NAME PHONE
(The individual to receive and a v(Nt...) �b b i lJ S 2e(o-5 7.5"-e 3 1
respond to all correspondence MAILING ADDRESS E-MAIL
concerning this application) 10 7 WAS l4 i,J(n 1 QA) BLVD.
CITY STATE ZIP FAX
AL1-0")14 1 14 98A° 1 253—7 3S----Lf 9 76e,
ALTERNATE CONTACT PHONE E-MAIL
ME LS &ko�tic- 2c(0.575-03 1 l
PROJECT FINANCING NAME
1 OWNER-FINANCED
Required value of$5,000 or more (��S.g�
(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.
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.
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SIGNATURE: DATE 2 2 x 1 2
gp..9.---
PRINT NAME: Robe-T d I eP
Bulletin#100—January 1,2011 Page 1 of 3 k:\Handouts\Permit Application