14-106375 • •
CITY OF
PERMIT APPLIGAZION
Federal Way
��(( DEC 15 2014
PERMIT NUMBER ( 4 � 0 3 -7g- EF CITY OF FEDERAL WAY
_ _ - _ _ _ _ _ _ TARGET DATE
CDS
SITE ADDRESS SUITE/UNIT#
3 Zbb 5I,/ ®,s-t-1- Pot T 12-014-1)
PROJECT VALUATION ZONING ASSESSOR'S TAX/PARCEL#
$ 35-7 00 • 1 - Z / 0 3 - 9 y 6
TYPE OF PERMIT ❑BUILDING ❑ PLUMBING ❑ MECHANICAL ❑ DEMOLITION ❑ENGINEERING KFIRE PREVENTION
NAME OF PROJECT DIJI th i S En✓ G 6-t'TA L
PROJECT DESCRIPTION lie PC F,//eL �.t/0 "1--bb
Detailed description of work to �-� � �/2� �.��/��"
be included on this permit only eke.V( C g-S P � rt A^ 'Tim 7.. 3'13.rM
NAME ( PRIMARY PHONE
PROPERTY OWNER (—( TT' 0f F-g-p €to L 1/l-1' 2S'3 -- 3 S- 2 00 0
MAILING ADDRESS E-MAIL
3200 5G•f b pot47 R ) R-062-6-77-016E2e c.err o( -:
CITY STATE 1 ZIP r'4 Qegelt_ ^I`/'-e -
/ 967ZA L wW 92 d 2,3 Cdr—
p E PHONE
PAC ir(L t=i2c - SE ,iK-c 70c,-95`7- .0 907
MAILING ADDRESS_ �1 /� E-MAIL n
CONTRACTOR
97_-S 'v PEA-r R F S . /2086-ATV @ Pnc I,F l L (=j Q.C:�
CITY STATE ZIP FAX ,5-67-44-4 l t o low
55/4 TriC (M4 f 1Yy 206726- N.160
WA STATE CONTRACTOR'S LICENSE# EXPIRATION DATE FEDERAL WAY BUSINESS LICENSE#
'/FG • FFS ) /1 ZroC /0 '. ,c)- 00— 4--
NAME PRIMARY PHONE
SA-A-45 5- cOn-rRA-c-1-072-
APPLICANT MAILING ADDRESS E-MAIL
CITY STATE ZIP FAX
NAME PRIMARY PHONE t`G c/
PROJECT CONTACT /7-<&e�T 1/A`U' to 24‘, -39/- 'l ` /
(The individual to receive and MAILING
ADDRESS_ E-MAIL
respond to all correspondence q 2 S Poi) L \K /c , ✓ u—1
/vJ E2 r VCt PK(F(c"F I Z
concerning this application) CITY STATE ZI FAX /FeP a I?'L(,co
56A-?T"L / c� - 6•AA `1 (4`( ZO.�-7 z6-- 4/60
PROJECT FINANCING NAME ^ ❑ OWNER-FINANCED
Required value of$5,000 or more HAM"? RaCITY,STATE,ZIP PHONE
(RCW 19.27.095)
I certify under penalty of perjury that I am the property owner or authorised 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 authorised 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 o his application.
SIGNATURE: DAT1 '/l t�j y
PRINT NAME: 12.0e VAu t f/"
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Bulletin#100—January 1,2013 Page 1 of 3 k:\Handouts\Penult Application