13-101695 f i
• yap o� E
CITY OF
PERMIT APPLICATION
Federal Way RECEIVED
PERMIT NUMBER ( — 1 V I 1 - 0 0 APR 18 2013
TARGET DATE
CITY OF FEDERAL WAY
SITE ADDRESS SUITE/ 7�#
> 5 3 c� ti c, 441a.y ?:;10 J 17
PROJECT VALUATION ZONING ASSESSOR'S TAX/PARCEL#
TYPE OF PERMIT ❑BUILDING 0 PLUMBING 0 MECHANICAL 0 DEMOLITION 0 ENGINEERING FIRE PREVENTION
NAME OF PROJECT l`I n,� f 1 j-D
PROJECT DESCRIPTION
Zn5kGl1 PES cc th rl
Detailed description of work to
be included on this permit only
- -- - - NAME PRIMARY PHONE_.
PROPERTY OWNER I c L` '1 1 6 e 5
MAILING ADDRESO� c3Ox (9 E-MAIL
CITI(��1.--0.(+1''\f
0 -STATE ZI� 1 l7v lJ ,
NAME \-.�IA.7�l n �r A In`n`n�c - - ----_ PR066 ,
MAILING AD - S , I_\��(��� \ �/r �E�-(My,A�yl tot;"47,s vQ'
CONTRACTOR ��`� (((( `' WA
Y ` [ )CITY�T ZC 1C3LfWA SZ ii
'SV ib /IRATION D13 76-(1)-115 TS.. FEDERAL WAY \� LICFIP-
NAME 5 A ^� /I _ fk PRIMARY PHONE _{A f
APPLICANT MAILING ADDRESS A /li!-AT�VI/1�( EMAIL
CITY STATE ZIP FAX
NAME 11`` �� r PRIMARY�y�PHONE
�
PROJECT CONTACT r` �' ((\ CJ�A7' �a -'YC60
(The individual to receive and MAILING ADDR S 2 /� L F.-
respond to all correspondence 1-01.0 JlJ ��C�O1 ` \/LII�Vj1Al%W�JhCPn{�
concerning this application) CITY �CAI-F ZIP4b
i,...3„../
FAX
nekr L 901 [
NAME
PROJECT FINANCING 0 OWNER-FINANCED
Required value of$5,000 or more MAILING ADDRESS,CITY,STATE,ZIP PHONE
(RCW 19.27095)
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 arty 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: 03‘/I'' ��� DATE q- 1.7-(/R 3
�' IG.Ar`-
PRINT NAME: VY\cJ tJt/tn l/
Bulletin#100-January 1,2013 Page 1 of 3 k:\Handouts\Permit Application