11-101258 ,,o} cI' PERMIT
• MF CO ME PL DE EN ii)
Federal
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0 F FEDERAL WAY
SITE ADDRES CD SUITE/UNIT#
220/ . <OMrao S
PROJECT VALUATION ZONING ASSESSOR'S TAX/PARCEL l//_PARCEL#
$ 5'3 600 U/. 0 0 1 A o 1 . () - 0 0 / D
TYPE OF PERMIT ❑ BUILDING ❑ PLUMBING El MECHANICAL
❑ DEMOLITION ❑ ENGINEERING FIRE PREVENTION
NAME OF PROJECT -
(Tenant Name/Homeowner Last Name) a.1 e 1
PROJECT DESCRIPTION 4, d. 221 ii.k (.7'G -I5 dv) Ale Coo ea / k(e S
Detailed description of work to Aye' /�i/c--e. ta AL --fl%K Ala k••-i. /4( WO S Taro /. •
be included on this permit only
NAME / / f/ (Va�o. PRIMARY PHONE
PROPERTY OWNER
MAILING ADDRESS E-MAIL
CITY STATE ZIP
NABIE �/ PHONE
NJJ la-Q c 5 p0G -772 -75Z 2
MAILING ADDR CONTRACTOR � 3l5 `<6 5 S. //` 5T.L l f •
2-i v(�i+(`WD%lt c ' k6
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CITY7-7/ta,`/`¢ I STATE Zyee- r FAX -772_7sv5/
WA STATE CONT CTOR'S LICENSE# EXPIRATION DATE FEDERAL WAY BUSINESS LICENSE#
(\l(AtiN P S VLP C(Z 2 / / / /z— .20-/d /0/ 5/27-00 , L
NAME O '7 v /�'5 I Q)L C ^
PHONE
APPLICANT MAILING ADDRESS A E-MAIL
CITY STATE ZIP FAX
PROJECT CONTACT NAME in , PHONE
(The individual to receive and PQ � .�fJ ��Z 7 S 2
respond to all correspondence MAILING ADDRESS / ft', E-MAIL
concerning this application) 3 /b'. � $ 14//b iSi�F r° if/ / //!f r of 5
_T$► STATE ZIP FAN-C1C/ v
/ 1/4icij r/ NAME: Witt. �'p/bp' 206-78 9l/2-- ? ' `,
ALTERNATE Cotc/A n nnt� PHONE G P�� (Wert-rt-e Sr .ld h
PROJECT FINANCING NAME '7� // 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 m• •- made by any person, including the undersigned,and filed against the city,
but only where such cl• out of the relic of the city, including its officers and employees, upon the accuracy of the
information supplied • the as - •art of this •-•lication.
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SIGNATURE: /p `1 DATE el- / //
PRINT NAME: f e i<1 44-,; 0
1letin#100-April 14,2010 Page 1 of 3 k:\I-Iandouts\Permit Application