13-101840 RECEIVE! !I - JLLQ
CITY OF PERMIT SF MF CO ME PL DE EN FP
Federal Wa P O
253-835-2607*U I7Y FAX PME T35-�9 S �O�APPLICATION c----------__________->
COMMUNITY DEVELOPMENT SERVICES
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— �.T OF FEDERAL WAY
CDS
SITE ADDRESS SUITE/UNIT S
// Ca G. CzmmonS • LArie Bryan'
PROJECT VALUATION ZONING ASSESSOR' TAli/PARCEL 11 2040 _ 0010
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TYPE OF PERMIT ❑BUILDING ❑ PLUMBING ❑ MECHANICAL
❑ DEMOLITION ❑ ENGINEERING ISit FIRE PREVENTION
NAME OF PROJECT , r N- V�f
(Tenant Name/Homeowner Last Name) �(�((�� -f (���j
PROJECT DESCRIPTION ' `'"'`— (f 7 )t) -e-•" . •
Detailed description of work to
be included on this permit only
NAME PRIMARY PHONE
PROPERTY OWNER *,1 • r—t �`, it A 1) /I t / / _ 4.
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NAME PHONE
G DRESSS ` E-MAIL y ' �^
CONTRACTOR f/\ \7 1 ... Q rOU) `�wr
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A EXPIRATION
C �fl M? .6414 L, " e /DATE FEDERAL WAY BUSINESS(, !9'9e/o tred LICENSE
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•AME PHONE
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APPLICANT MAILING ADDRESS E-MAIL
CITY STATE ZIP FAX
PROJECT CONTACT Q '7/04''W 7 �f
(T a individual to receive and N 11-IC V1 S()1 '`l0�
respond to all correspondence MAILING ADDRESS E MAI
concerning this application) _ I. _ Ot1 "O.
CITY STATE ZIP "AX f
ALTERNATE CONTACT NAME: PHONE E-MAIL
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PROJECT FINANCING NAME t
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 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 he city as a part of this application.
SIGNATURE: - '1M, I a L /1L DATE - 2' +l
PRINT NAME: _ _ t �J A PIa
Bulletin#100—January 1,2011 Page 1 of 3 k:\Handouts\Pennit Application