13-101613 RECEIVED
CITY OF PERMIT!APPLICATION
Federal Way APR 12 20
CITY OF FEDERAL WAY
CDS
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PERMIT NUMBER / 3 _ / ® / 6 ( 3 _ F P
IIII.LVVV� TARGET DATE
SITE ADDRESS SUITE/UNIT#
/VS rnw1 O St re GLQ 1 WAU-)) ) UJ A
PROJECT VALUATION ZONING ASSESSOR'S TAX/PARCEL#
$ 8S2.. (422Li0 _ 00a
TYPE OF PERMIT ❑ BUILDING ❑ PLUMBING ❑ MECHANICAL ❑ DEMOLITION ❑ ENGINEERING FIRE PREVENTION
I tr
NAME OF PROJECT ►.. ■ '1 ` r �, � '�7� Ii
PROJECT DESCRIPTION ,,)� y `_ • t ' C\, `• • a• 1` A
Detailed description of work to r__ \T .Ai Yi • G • • A _ 4 I •
be included on this permit only L C_0 ' S•
NAME PRIMARY PHONE
PROPERTY OWNER L`fldYNmOYA S \l\ LLC !jL( cictlCI
I.'/J\0 VR�Y o 1 � rl 1 Akre, `i E-MAIL
CITY 0 STA E ZI
NAM�.(C VIN QY 46- (Ad- t V `J-1) 1:5611 n 12,1 .V 14 V
MAILING ADDR E-MAIL n
CONTRACTOR WOO 12 Ave . ter', `► 1�-b∎k r (�A,y,,�/��
CITY STATE ZI B t (38 LJ try &3 -2 V/O ca'
WA STATE CONTRACTOR'S LIC �c V� "I EXPIRATION DATE FEDERAL WAY BUSINESS LICENSE#
it-So�—_c____ CR L. Iii ( / I?) !a1-q6- to55 ►-oo-f31.-
NAME \ y ` ^ a � ti..6e-, PRIMARY PHONE
APPLICANT MAILING ADDRESS-�1V� G_J�JI E-MAIL
CITY STATE ZIP FAX
NAME PRIMARY PHONE
PROJECT CONTACT 30 C f.1C) SR�L /45.. V-47
(The individual to receive and MAILING ADDR]CSS .-3M E-MAIL
respond to all correspondence ..cl.\00 k.?,
concerning this application) ct" e�,, J w�TE ZIP 8 '0 13 FAX
\J ,�'jt Jp� V�14�
NAME
PROJECT FINANCING ❑ OWNER-FINANCED
Required value of$5,000 or more MAILING ADDRESS,CITY,STATE,ZIP PHONE
(RCW 19.27.095)
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. ., i
SIGNATURE: .���_.1 - ___ DATE !w 3
PRINT NAME: ....11A. SGI-cM
Bulletin#100—January 1,2013 Page 1 of 3 k:\Handouts\Permit Application