15-100152 k
1 `
CITY OF PERMIT IIPPLICATION
Federal Way RECEIVED
PERMIT NUMBER
5 1 0 0 1 57---- Fr JAN 1 2015
-
_ TARGET DATE CITY OF FEDERpti WAY
CDS
SITE ADDRESS SUITE/UNIT#
I
PROJECT VALUATION ZONING ASSESSOR'S TAX/PARCEL#
$ ►cil6()'■ z 1 9 2 0 - a 5—
TYPE OF PERMIT ❑ BUILDING ❑ PLUMBING ❑ MECHANICAL ❑ DEMOLITION/❑ ENGINEERING 21 FIRE PREVENTION
NAME OF PROJECT vS-1;' k`(, ( Ir1I5LY.) SU-)1-� SO�vk. C\,./)\(.
PROJECT DESCRIPTION C 1 \1 I C`
Detailed description of work to h L n 1 t��S 't"`� n�t ,),,,\ t\V■-(.._
be included on this permit only
NAME 11 (' PRIMARY PHONE
PROPERTY OWNER S e;,.--t1 Z CV)\\1(`O , Z-( 01 '1,-0'3
MAILING ADDRESS E-MAIL
p
a6e; J 0\.-3.. 90;1\1 w l,7 l\jF-
CITY SATE ZIP
S{.- \k. \A pi `k 1oS .
11�� PHONE
NAMfS I.c.T"f�A \n ° \ k-126.710 J -?- t-(o s1
■MAILING ADDRESS .
CONTRACTOR -- 5 5 S S e>41- , 'C Q A N N ry IIoI�,rcL�c1 1� fv1�i�.Co w
CITY
— _ `,/j ��N�� STATE E Z( „ c1-�� FAR
WA STATE wMTRACTOR'S LICENSE# W EXPIRATION DATE FEDERAL WAY BUSINESS LICENSE#
/ /
\\ 11 11•
NAM e --.Y '\Al^J4"t"l., PRIMARY
Z`� lSi`�C7 PHONE
MAILING ADDRESS 1 �+ �� E-MAIL I
APPLICANT
5555 \ie 7�-e, Ft 11 t ,k I V M �l u^ a .Q5\111/1 j— 'Co"
CITY 1 STATE ZIP FAX J
5;Ii;.t�ill-\k. A 1143`53
NAME L 11 PRIMARY PHONE -7
PROJECT CONTACT (\ -- ?)\�v1�y Pr(, ZULD - I`�`CAS
(The individual to receive and
MAILING ADDRESS `` 1 ` E-MAIL /�
respond to all correspondence 5.5S,(:) VI t>T0�^t-t ff u,1- N ' M 00,-_ A{ d�53 m(3, •(o e,
concerning this application) CITY STATE ZIP FAX
S,-1Vcr ,,1�, W A 6'13 --}
NAME OWNER-FINANCED
PROJECT FINANCING
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 apart of this application.
SIGNATURE: GM AF 1F ri/V,JV DATE I/PI I
PRINT NAME: 1"\4 \(,0,-\6.-4—A-1-k,
Bulletin#100-January 1,2013 Page 1 of 3 kAHandouts\Permit Application