13-101839 J M
t P.ECE D 11113 - / D / ? S '
CITY OF A PERMIT SF MF CO ME PL DE E dp
Federal Way 'APR 2 4/ill
COMMUNITY DEVELOPMENT SERVICES C iTI O i •
u'ww.oluo tops_ i e '( OF FEDERAL WAY www.ciluof(edernlwm.co
CDS
SITE ADDRESS SUITE/UNIT#
1I ` S. Cotr7rrlans • Ca--her/ries
PROJECT VALUATION ZONING ASSESSORS TAX/PARCEL#
•
II
TYPE OF PERMIT BUILDING ❑ PLUMBING ❑ MECHANICAL
❑ DEMOLITION ❑ ENGINEERING FIRE PREVENTION
NAME OF PROJECT /`
" IV
(Tenant Name/Homeowner Last Name)
/60,40t (co) -Fire_ s pc/F7/c rr 7 S •
PR OJECT DESCRIPTION
.
Detailed description of work to
be included on this permit only
NAME /� / PRIMARY PHONE _
PROPERTY OWNER �/f/�4,/1 s+ ( o ?/n va / Dp ' /9.1,0,23-770(7
G ADDRESS E-MAIL '
g lop V� �.7 in n '# .
CITY A E ZIP
r vine_ 92( J2
N PHONE
Wrt P)r-P rn r f1 I`fc 1/2S-�1/• lag
Cam, 710
NW.ING ADttD S 2 E-MAIL`S ��//��.��
CONTRACTOR M i� iZi;3 i�.S�StaleC '`-`"'�/
CITY STATE ZIP .WAX
mill Crree,tc_ wA gZg2__ 2-0-1;• 440469S-
WA
--- - STATE '" J-D 914 �5 N /f( L FED 9'S LICENSE
'6 L
NAMFy, _ �c 5 CO7+0 • PHONE
APPLICANT MAILING ADDRES E-MAIL
CITY STATE ZIP FAX
PROJECT CONTACT /�_ t C� r C�» PHONE/24 ' r�!• /
respond to all correspondence
MAILING ADDRESS E-MAIL
concerning this application)
CITY STATE ZIP FAX
ALTERNATE CONTACT NAME: PHONE E-MAIL n .�I�'/(`�_]
_ e csic _a L'r an
PROJECT FINANCING NAME T
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 t' he city as a part of this application.
SIGNATURE: '1'�
. /r Ai ,i i DATE 11.24-/.13
PRINT NAME: _i' IWL, •/1/j
Bulletin#100—January 1,2011 Page 1 of 3 kAHandouts\Permit Application