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14-105248r CITY OF • PERMITIKPPLIGaON Federal Way OCT 0 92014 PERMIT NUMBER I 4 - ( 0 5 _ F�P CITY OF FEDERAL WAY Z \\ v TARGET DATE CDS SITE ADDRESS SUITE/UNIT#4#./2°" Celiie A PROJECT VALUATION ZONING ASSESSOR'S TAX PAR # 2- 4 O - O 0 ' ,^ $ A49616°TYPE OF PERMIT ❑ BUILDING ❑ PLUMBING/❑ MECHANICAL ❑ DEMOLITION ❑ ENGINEERING JQFIRE PREVENTION NAME OF PROJECT e_,�T/� //�),4 /� PROJECT DESCRIPTION c?: /W//1,Y)✓ F re C!l©4 ( 71-_ _ `� Detailed description of work to be included on this permit only NAME PRIMARY PHONE t PROPERTY OWNER � Ali • >A MAILING ADDRESS E-MAIL CITY STATE ZIP ' NAME )4 ' Qy P1 � _ F' ... PHA%�'°Y -� `7CS MAILING ADDRESS �7� / (f I'l 1 _,// /y, �// CONTRACTOR ��JJvv�l 0 `�TJ'� �p //,1/. /f�J(Jf'�/(r l/�(1/1 fL1 W CITY A TATE 4 7' E STATE_ 78/71' TE FEDERAL WAY BUSINESS LICENSE# 1 NAME flu)`�/ ' .37 3 APPLICANT MAILING D o / / FE/'/�M!/A�IJ/L,a�' 72,M >� CITY p TATE ZI //t7�/�j� FAX f L tC/k- ?w/I / P Y PHONE _. NAME / ��f PROJECT CONTACT '�Alt LO -f ��i`� SGC�S� 7 / 3 (The individual to receive and MAILING ADDRESS EMAIL R ®�p-,p /A�/77 respond to all correspondence M�"P W N(V yam! f �Z/ concerning this application) CITY STATE Z � FAX l tAl �/� PROJECT FINANCING NAME ❑ 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 clai arises out of the r- ance of the city, •ing its officers and employees, upon the accuracy of the information supplied to city as a part of th"/ale-•cation. �� 10J'-� SIGNATURE: ii DATE PRINT NAME: taia lfG��/11I�11�, y -- Bulletin#100—January 1,2013 Page 1 of 3 k:\Handouts\Permit Application