16-106031 greIVED
•
CRT OF A .,.,r - ,1, Ilit,i PERMIT APPLICATION
Federal Way
of MalliZAL WAY
PERMIT NUMBER i /_ /_ 6 6 0 3 - E
.(f� ` CC«// ✓✓✓ TARGET DATE
SITE ADDRESS I SUITE/UNIT#
fray Z' 5 33 5 3a ?u i.,5 5 ----
—
PROJECT VALUATION ZONING ASSESSOR'S TAX/PARCEL#
$ t;r 2q t � 9 7 0 2- D _ O o 5 D
TYPE OF PERMIT ❑ BUILDING ❑ PLUMBING ❑ MECHANICAL ❑ DEMOLITION ❑ ENGINEERING AFIRE PREVENTION
NAME OF PROJECT F(d'1-a /1c- A f--- PA-g-T'S
Pro lr, Qtr Ai.r.'v Dic-rt_ 4 SAP v1# < F. �
PROJECT DESCRIPTION Q Q
Detailed description of work to SC /L,,M�t_E12. �`(S�Ff`''t t '�- JV,C/) &..ILlAt
be included on this permit only
?TA-e-il nror t4-1- f't-/4e4-E. lt1i0.427 S ID C e.,� C/ i,
iNAME PRIMARY PHONE
PROPERTY OWNER girs. f _ 4141Y F'h/ AR Lt_C
MAILING ADDRESS 7r-/0 47 E-MAIL
4-o o S, f:w S
CI two STATE fc)finviedic.
ZIP
4-4A/to D 1fr a-4 a- .e o 1 I
NAME PHONE
_ ko ct44 47n/5 Tl►- ac-7L,!)
MAILING ADDRESS ? ,, E-MAIL
CONTRACTOR -6 5 5- 5 ` 6, 5`
CITY C� -- BT�� FAX
KY ZIP il e o Z—
WA STATE CONTRACTOR'S LI ENSE# EXPIRATION DATE FEDERAL WAY BUSINESS LICENSE#
Aft E.) - . 1 Di_ 4 I 17 _,
NAME PRIMARY PHONE r
rj defr't.E S 4,'/LIG Anil 2.v --o 0 — l 0 1 `FG 3+-0 0
APPLICANT MAILING ADDRESS E-MAIL jRL
CITY STATE ZIP FAX
.
NAME PRIMARY PHONE
PROJECT CONTACT T D 0 ,/r- rJ gyp(- Zq 3-Zl 5 4..
(The individual to receive and MAILING ADDRESS E-MAIL
respond to all correspondence 't-q v.4_.Gs1 arale c
concerning this application) CITY STATE ' ZIP FAX caN5 j 1t C 7,?0 , 4)44
PROJECT FINANCING NAME 0 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 ci as a part of this application. r
SIGNATURE: DATE _ I Z ` --- {D
PRINT NAME: Tr D 0 L1
Bulletin#100-January 1,2013 Page 1 of 3 k:\Handouts\Pemrit Application