12-105657 fiZ _ 10565-7
F . � CEIVED• PERMIT SF MF CO ME PL DE EN
Federal w
COMMUNITY DEVELOPMENT SIe 2 0 2012 AP P LICAT I O N
253-835-2607•FAX 253-835-
www.cituoffecleralwau.com
CITY OF FEDERAL WAY
CDS
SITE ADDRESS 9 21:03 SUITE/UNIT#
3 OZc) 6ei-Bcrfed Lk � -Poie i 1A119 Goa
PROJECT VALUATION ZONING ASS SOR'S TAX/PARCEL#
TYPE OF PERMIT El BUILDING ❑ PLUMBING ❑ MECHANICAL
❑ DEMOLITION ❑ ENGINEERING FIRE PREVENTION
NAME OF PROJECT l� r / ( T
(Tenant Name/Homeowner Last Name) ,1/\�1^ (1)66:y _L�L7 C n ydi iii.I`% �
PROJECT DESCRIPTION . // ^ -/ ---�^� �r —
Detailed description of work to -F 4 r(( 1 k � I 4
be included on this permit only
NAME PRIMARY PHONE
PROPERTY OWNER bI.h�4J O� j S .��CI
GAD S /�"-'"� E-MAIL
CITY
0g.1ah - C!a"til Z 3I -Q
2SX iQYc d —5
PHONE -2i
it011AD6�s t ° Ni E-MAIL CONTRACTOR
Of, �-�I c� ( 8329 FAX 7:,33-23--Z3I 2
E Z er r'$m Eom ^ EXPIRATION DATE FEDERAL WAY BUSINESS LICENSE#
/ O ( jn� f .
PHONE -3--zQ I
O
EMAIL
APPLICANT r ® , D re Xiazad a \/
M+1111-400g 71ZE0 92 3 2_4,9 FAX
PROJECT CONTACT nn^ off-, d ;;�n g - - -CJ�� +
(The individual to receive and 1I UU�-[ �IC_(J
respond to all correspondence MAILING 1y {� �� /)
E-MAIL
concerning this application) i k ► Q_t
\\, (, - $3`Zq 2.S3 -Z'`-9-- zc -P
T CONTILy.N PHONE E-MAIL
10-/Zl
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.
SIGNAT • 'O L i 0 I A AO, DATE 0 r I 9-I 2—
PRINT NAME: Anom Il or .'t L
Bulletin#100-January 1,2011 Page 1 of 3 k:\Handouts\Permit Application