17-100255 •
•
CITY OF
► PERMIT APPLICATION
Federa I Way PERMIT CENTER+33325 8'"Avenue South A 98003-6325
253-835-2607+FAX 253-835-2609+permitcenter(acityoffederalway.com
JAN 18 2017
PERMIT NUMBER i _ ( 0 0 25 5 _ 1 °�,! OF
- __ __ TARGET DATE
SITE ADDRESS SUITE/UNIT M
30 'R*ax.. A (■a - ' 1 .dpi r°z( 0 1 Imo-
PROJECT VALUATION • ZONING ASSESSOR'S TAX/PARCEL S
$ 3t, 6,2o ,..0 7 9 7 P, 2.. o - o o G a
TYPE OF PERMIT ❑BUILDING ❑PLUMBING ❑ MECHANICAL ❑ DEMOLITION ❑ENGINEERING )4 FIRE PREVENTION
NAME OF PROJECT /S viCezNi AY1 t U
L44141 Oricif crr^ivd Pi l• (I'e.
PROJECT DESCRIPTION
Detailed description of work to
be included on this permit only
NAME 1 PRIMARY PHONE
}Al
/ 1p-y P/11per4leS 2_0 to - 2t/Io -'4 co,Co
j PROPERTY OWNER MAILING ADDRESS E-MAIL
t7°)23 IZWter& ?L-SQ
r ( STATE ZIP
NAME PHONE
L-1 CM() & >r1'?rI ce> Iy1c 25 3 '2)14-tr,(s)2
CONTRACTOR MAILING ADDRESS �? - �1Cs 1lotfa ri sAt Y.`C.CD'w
CITY STATE ZIP FAX
kectc.ra4 V)scA tA) --. °>¢,O(43 253 f42.)01 a 3
WA STATE CONTRACTOR'S LICENSE 11 EXPIRATION DATE FEDERAL WAY BUSINESS LICENSE it
....t...041)I Ac 23GAF,4 y / I ¶i2^'17 2o --co -101_13g-ObeL
NAME PRIMARY PHONE
LIOI-(o1 cAvt41.ee.r pr15S Za c 2527 2774_ C>4.1',)Z
APPLICANT MAILING ADDRESS E-MAIL
Pa 1G7c4c, 3 ') \Cefol ilq I IIOLIdoclare✓'1st}lhC.r
CITY STATE ZIP FAX
f"42-C)-(a.al 1,A)7,.1 w ._ -cx 6,3 225 ^03rd' -0 I O 3
NAME f PRIMARY PHONE
PROJECT CONTACT L t o Ltd Cv1`try)r 1�,e-- "Lc &.,e-A4 (-k-Clwl;',.t ) 2_5 3 035" fc,(o1 3
(The individual to receive and MAILING ADDRESS n E-MAIL
Pct 1 ) Ke,�12'a I I v dell ete �,s-Psi c.ce-'
respond to all correspondence n
concerning this application) CITY �" t� STATE ZIP FAX
PROJECT FINANCING NA�It
(IE '(-)iv ri./10: x OWNER-FINANCED
When value is$5,000 or more MAILING ADDRESS, ,STATE,ZIP/� �7 PHONE
/RCW 19.27,095) loll?2 / 2 l��`t�/.1 �L. '`i , �e,s-1A1 v1 A..trL- ( ., c tr- 241, '-c')f&
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 p art of this application.
SIGNATURE: _ I ^ DATE j//// 7
PRINT NAME: ev [i( .-,
Bulletin#100-January 29,2016 Page 1 of 2 k:\Handouts\Permit Application