13-104258 3 _.E.a
•
CITY OF PERMIT
Federal Way �� 4 MF CO ME PL DE EN FP
COMMUNITY DEVELOPMENT SERVICES APP LI CAT I O j VE®
253-835-2607•FAX 253-835-2609
www.cftGoffederalwus.corn SEP n 5 2013
rrry SITE ADDRESS OF�EOI RAL WAy SUITE/UNIT#
�. i z COS
p OLS-'-- l _ . € A (.tl.�,C (Lb
PROJECT VALUATION ZONING ASSESSOR'S TAX/PARCEL#
TYPE OF PERMIT
0 BUILDING ❑ PLUMBING 0 MECHANICAL
0 DEMOLITION 0 ENGINEERING X FIRE PREVENTION
NAME OF PROJECT G A E��1 }T- ) �/ L
(Tenant Name/Homeowner Last Name) Y' t V �111V I C/ 1V� ���CI""l �7
PROJECT DESCRIPTION e_. lC -" +� 1 e A
Detailed description of work to
be included on this permit only
NAME,-,- -.._ PRIMARY PHONE
PROPERTY OWNER ___Cl._. \+ G ` C t- Lc
1 INV DRECI � --V ., E-INAII.
ATE
LNG AD)RF.SS-- 1 ‘......E..-MAIL
CC t <� T f� ' 1 'e '�l�i�i�.iY\ >fro'-
CONTRACTOR s_kiI (�
-T---u,V LO t \a_ / TE ZIP F FAX;.,
t:} two{UIJrJ -""
ISLitt„ Ci
�C TATE CONTRACTOR'S L ENS # EXPIRATION DATE FEDERAL WAY BUSINESS LICENSE#
I U q! •
/ CSC?U \ ZVs 1 � J �3 / )0 / J 44
` NAME PHONE
APPLICANT MAILING ADDRESS E-MAIL
CITY STATE ZIP FAX
PROJECT CONTACT NAME PHONE
(The individual to receive and
respond to all correspondence MAILING ADDRESS E-MAIL
concerning this application)
CITY STATE ZIP FAX
ALTERNATE CONTACT NAME: PHONE E-MAIL
PROJECT FINANCING NAME
❑ 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 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 of this application.
SIGNATURE: ili a/&, ,ii J DATE 9/2-C1 13
PRINT NAME: A ' s -E:rx_r-,12
Bulletin#100-January 1,2011 Page 1 of 3 k:\Handouts\Permit Application