12-103164 2,
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ci,„,A.,Federal Way _
Fe RECEIVED PERMIT SF MF CO ME PL DE EN FP
'1 �p
COMMUNITY DEVELOPMENT SERVr4U L 10 2M�P P LI CATION g
253-835-2607•FAX 253-835-2609 ��`iii ��
cvu�w.cituotfederatu�at.co�_r; OF FEDERAL WAY 0-~
CDS
SITE ADDRESS SUITE/UNIT 8
3502. S eKe4 4✓hiej Povi y S. Auk
PROJECT VALUATION ZONING ASSESSOR'S TAX/PARCEL#
$ 857a A-3, $ I F1 $ 25 S - 0 o 3 0
TYPE OF PERMIT ❑BUILDING ❑ PLUMBING ❑ MECHANICAL
❑ DEMOLITION ❑ ENGINEERING XI FIRE PREVENTION
NAME OF PROJECT
(Tenant Name/Homeowner Last Name) Tr-4 vH aOI t'et e Mai/0 el
4etd anpl re to cc.* se 1 i.1klefS 74, r- ne t.✓ we/(5
PROJECT DESCRIPTION l ,
Detailed description of work to e e l''MS 4^Of l°l``144- a"'l
be included on this permit only
NAME ,
PRIMARY PHONE
PROPERTY OWNER ( c O Feek/C ` C✓G y CrocjI,L�f zee--5 • /72—..5
16 i 11,t' ,d„e fe. .S /32 / E-MAIL
CITY STATE ZIP
g e uewl c. W,¢ 1 roo y
NAME
SM a 1 i' PHONE
Fr e 5/57/4.—s z s3 /id/11"
MAILING ADDRESS E-MAIL
CONTRACTOR //e6 S�t°h 4ve e- 31 9.--1/Qf•-u;14,0: 'to"a'.,
CITY STATE ZIP FAX
`
r"0,1".01 1+,4- car''a y r s 3 gars z i
WA STATE CONTRACTOR'S LICENSE S EXPIRATION DATE FEDERAL WAY BUSINESS LICENSE S
M27/,FS'/360 7 I /)1 /Ix. if IS"oo6e SS 00 el-
,
-
NAME PHONE
)Ob.✓ lei-kecl,co/ (Sr ;fi,6Y�) 7—$3 2`tS>ass 9
APPLICANT G ADDRESS E-MAIL
lab' 59f-e.y 6 A )6An/ s•-.A4)- &
cll�c..('6vK� S M ZIP Z.T Zs3 70 t_
� 3SO
PROJECT CONTACT
NAME Cs�`� k S 4 ^^i/1-4 A._/ PHONE
(The individual to receive and �✓ ]_
respond to all correspondence MAILING ADDRESS E-MAIL
concerning this application)
CITY STATE ZIP FAX
ALTERNATE CONTACT NAME: PHONE E-MAIL
N% l/e - e r' zs3 z.11 2(d n to er r-C 5,%#'74)e%ofekeloAl
PROJECT FINANCING NAME
�� OWNER-FINANCED
Required value of$5,000 or more
(RCW 19.27.095) MAILING ADDRESS,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: 1W ,n///*i ^ DATE 7-9'—rZ
PRINT NAME: J O k" !L& ke-e". .),‘47(
e
Bulletin#100—January 1,2011 Page 1 of 3 k:A1-Iandouts\Permit Application