13-103989 '�`of , ,, PERMIT APPLICATION
Federal Way a `' , P' RECEIVED
I
PERMIT NUMBER 1 17 - I 0 'v9 5 q - ,r SEP 10 2013
TARGET DATE CITY OF FEDERAL WAY
SITE ADDRESS SUITE/c2 #
3So t PS Way GC
PROJECT VALUATION ZONING ASSESSOR'S TAX/PARCEL#
$ 626°° C( k2_ & 14 - Q I 6 a
TYPE OF PERMIT ❑ BUILDING D PLUMBING ❑ MECHANICAL D DEMOLITION 0 ENGINEERING (S HIRE PREVENTION
NAME OF PROJECT VA SH J n)G N rA P j I ( L� � ' 1 ,'
PROJECT DESCRIPTION c ou+ STS - Mei+e` Ng'{, dic6l}4.1 celIuIrr� ' M)4L.0
Detailed description of work to
be included on this permit only
NAME PRIMARY PHONE
PROPERTY OWNER b1\ . .. Oteme``'er
MAILING ADDRESS � E-MAIL
I5 ' 2b*- e ( stAe 2.10
CITY STATE ZIP
GkGdsk ,2 Of
NAME WNsh(I ic`IIJ� 'hawk 1'c l PHONE `'V• 34
MAILING ADD�S/S'� J � � � / � E-MAIL ��,, `-�,,
CONTRACTOR (rD/0 At~ r \y,�lam„`� 4 -iI � .. '�►0�+�1�'e ani
CITY(r�, I .ke STATEZIP ^N illi13 Lf FAX
gbh/422-7z
422- /{. 1 14
WA STA/T(I�r/�alCTOR'S LICEN #2���V 12 EXPIRATION DATE 20-06-1O16? LICENSEL
NAME •ej-/y�l\ C(//•�(,`J 'LL)// ( , PRIMARY PHONE `/J�`�/
C. P6 Qict
APPLICANT MAILING ADDRESS E-MAIL
CITY STATE ZIP FAX
NAME PRIMARY PHONE
PROJECT CONTACT MC < MCzh n gee- 32
(The individual to receive and MAILING ADD ssgqqq n/� 11 'I E MAI
respond to all correspondence '�lJ Ai,*
1h(c� • �ibjO i 46114 I
concerning this application) CITY eel,\e sT r> ZIP^ 1 7� fiz322-
14
NAME
PROJECT FINANCING 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 thecityas a part
toffthis application. C� /
SIGNATURE: � '�I i''/%---s DATE ( ~(� /)
PRINT NAME: PActl j,1 te(-1we 1v\
Bulletin#100-January 1,2013 Page 1 of 3 k:AHandouts\Permit Application