13-101111 � ( - 1 ° ( 11 \
are OF '.-'' *PERMIT WMF CO ME PL DE EN P
Federal Way
COMMUNITY DEVELOPMENT SERVICES APPLICATION RECEIVED
253-835-2607.FAX 253 835-2609
+ !%'.:c�y�r(�e•a;! r i r.,�.r;.. MAR 08 2013 '7b
SITE ADDRESS CPPN'EJP FEDERAL WAY
12-ti.'7 S W Dash ?o i 4- {' ci cos
PROJECT VALUATION ZONING ASSESSOR'S TAX/PARCEL It
$ �2.1000 ,00 l 2 Z I D 3 - CJ S Z
TYPE OF PERMIT ❑ BUILDING ❑ PLUMBING 111 MECHANICAL
❑ DEMOLITION ❑ ENGINEERING X FIRE PREVENTION
NAME OF PROJECT
(Tenant Name/Homeowner Last Name) Way s ( el.& C hl,(,v►f-(-1
PROJECT DESCRIPTION Ihs Tom.`t a��'0 w to-l--I G 1��o i1 e-r(tJC,L( V.'s T-sI 1 y2.4, F6 P�T-
Detailed description of work to I.0 1 (NG ter S" cl r t a.14s'n-I I rs ys�► (exc ee-I- Hort,Vs-h�lle
be included on this permit only GLW•CKI f ) rj-Srer^ Pr'ttGtLGt-d drA.a I IL 9 S
~
NAME `J ^ PRIMARY PHONE
PROPERTY OWNER (A)a-(( S Z ck C o✓\ Q r 1 et- ov.f,' (kL.4
MAILING ADDRESS ,,J E-MAIL�.
312-4{'7 -5 w -04S 11 l -4.• d
CITY
e. STATE ZIP D Z3
NAME PHONE
Meldim S,rr:ur;f2- rclec-4 C zr3 co32r- 1-Z
MAILING DRESS E-MAIL
D i3'D y 71 cote/vieerW4 tcu r/ .bs
CONTRACTOR � r � 5 '�
CITY U' ` Z(-P�•'•-' 780 't2 FAX
6,30 0314,
WA STATE CONT CTOR'S LICENSE It EXPIRATION DATE FEDERAL WAY BUSINESS LICENSE It
IYl e N c 61 S-c a- 5 /13 // 2 v-04,-too t s-r-o
o -19L
NAME 5^, �S a 6 0 u-r€ ^ PHONE
APPLICANT MAILING ADDRESS (`r� E-MAIL
CITY STATE ZIP FAX
PROJECT CONTACT NAME PHONE
(The individual to receive and 5CO H a-c~•/ S 5 a"-A. Q`s bo se
respond to all correspondence MAILING ADDRESS n a E-MAIL
concerning this application) st-otfemev-1 C�1 ctose.0-LI V"I ,62,.�" "
CITY STATE ZIP FAX
ALTERNATE CONTACT NAME: PHONE E-MAIL
-
PROJECT FINANCING
NAME�(/ D OWNER-FINANCED
Required value of$5,000 or more /
(RCW 19.270951 MAILING DRESS,CITY,STATE,ZIP PHONE
I certify under penalty of perjury that I am the property owner or authorized agent of the property owner.I certify that to the best
of my knowledge, the information submitted in support of this permit application is true and correct.I certify that I will comply with
all applicable City of Federal Way regulations pertaining to the work authorized by the issuance of a permit. I understand that the
issuance of this permit does not remove the owner's responsibility for compliance with local, state, or federal laws regulating
construction or environmental laws.
I further agree to hold harmless the City of Federal Way as to any claim(including costs, expenses,and attorneys'fees incurred in
the investigation and defense of such claim), which may be made by any person,including the undersigned,and filed against the city,
but only where such claim arises out of the reliance of th
y f f e city, including its officers and employees, upon the accuracy of the
information supplied to the city as a p of this application.
SIGNATURE: 4 DATE 3—$-/
PRINT NAME: Flo o T!a Ot-fe-/S
Bulletin#100-January 1,2011 Page 1 of 3 k:\1-Iandouts\Permit Application