12-104760 • io .1x- 60
" RECEIVED PERMIT SF MF CO ME PL DE E FP
Federal Way rr q
COMMUNITY DEVELOPMENT SERIE6T 1 7 2011iPPLICATION
253-835-260 7•FAX 253-835-2609
icurw.cttun,federal,uuLI I Y OF FEDERAL WAY
CDS
SITE ADDRESS SUITE/UNIT#
35 a.o i_meAkc=s•,- %.... "?(- Ak.,t..wc\"1 S o\��r
PROJECT VALUATION ZONING ASSESSOR'S TAX/PARCEL#
$ 3%i97t0 31 Z 1 9 2 Ca 0 - 0 g o
TYPE OF PERMIT ❑BUILDING ❑ PLUMBING ❑ MECHANICAL
❑ DEMOLITION ❑ ENGINEERING ,FIRE PREVENTION
NAME OF PROJECT
(Tenant Name/Homeowner Last Name)
\\rr6C`I 1 r,ck(iNj
PROJECT DESCRIPTION
Detnilpd description of work to \\•451A\\, '�. •+.� F \Q--`L %\-k\0-`l\r\ S \ t•-1\1\
be included on this permit only
NAME PRIMARY PHONE
PROPERTY OWNER
MAILING ADDRESS E-MAIL
CITY STATE ZIP
NAME PHONE
�.�.‘,.4-� '0...=1. --'r S`/2C.t AL\-"c's\ Lt CI % ‘46, 1,
MAILING ADDRESS E-MAIL
CONTRACTOR S'1 L q C\A!,-`I Q.0kr StLos:e_KA A - -S4.i...vQ-ry.4An,`.
CITY STATE ZIP FAX
"Ze3-...1'\ 01v \ _ c\`6oS 1
WA STATE CONTRACTOR'S LICENSE# EXPIRATION DATE FEDERAL WAY BUSINESS LICENSE#
CX-Y?7a? lci-ci`i- 101(3,,1-Oo-6 -
NAME PHONE
N'.`,\ '- F\ct_s A SCA__ ,v L v
APPLICANT MAILING ADDRESS E-MAIL
C)S'\ Ca \ ' -"\. CLITh
CITY STATE ZIP FAX
Q-4 v- -O \ e gXoS-1
PROJECT CONTACT G I
(The individual to receive and NAME (-L,\\— S 1 �,a� i qi Le 4 5C Z
respond to all correspondence MAILING ADDRESS E-MAIL
concerning this application) 1O \ \I l --ti1 ?_-O C) SQASI- PU,►ti3O— "L_O—V IL rjsc-0 4 \
CITY STATE ZIP FAX
Z-‘0 d t•---k 1c • t O 1
ALTERNATE CONTACT NAME: PHONE E-MAIL
PROJECT FINANCING NAME 0 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 : .,_,which may be made by any person,including the undersigned,and filed against the city,
but only where suc aim arises , t of t relia a of the city, including its officers and employees, upon the accuracy of the
information suppli-, , he city as ,part o t a,, ,t ,
SIGNATURE: `�;
DATE 1 /1 17- --
PRINT NAME: . / I!! 1�-- ' T'
Bulletin#100—January 1,2011 Page 1 of 3 k:U-Iandouts\Permit Application