11-101513 -.-
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c,,A RECEIVit
Federal Way PERMIT SF MF CO ME PL DE E FP
COMMUNIIYDEVELOPMENT SERVIMR G o APPLICATION al" - .
253-835.2607•FAX 253-835-2609 ! �} PI. .
u�uu�.cityorlederalwau:o rt Y OF FEDERAL WAY (,�✓i{y�� CCC..���"` �,.
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SITE ADDRESS
C". -SUITE
`33 3oi t S+ f.swi-( 5CN i N -# /fo
PROJECT VALUATION ZONING ASSESSOR'S TAX/PARCEL#
$ f r'366 Z 6 s 0 4 - d
TYPE OF PERMIT 0 BUILDING 0 PLUMBING 0 MECHANICAL
0 DEMOLITION 0 ENGINEERING2E PREVENTION
NAME OF PROJECT
(Tenant Name/Homeowner Lost Name) C b ii,„..ei /�// (�^\ .� e.�5
PROJECT DESCRIPTION `: 1
DerailPd description of work to ADO l e_C; t O CA TV D ki i C .S P F it_ e(. 0
be included on this permit only
•THL L 'tel S-r 1 A(a F-7\V_-e- Art-A-Z M
NAME PRIMARY PHONE
PROPERTY OWNER n e(L y.,..„A „-r E . co/^ PA-A t z3 ..."714) - -g`i 0 0
MAILING ADDRESS E-MAH,
I%Z C, -4 L)c 5 . tf - 1 o '
CITY STATE ZIP
ic e.,N-r- (, r 9012..
NAME PHONE
F 1 e_� P F--4-)re-c.-711 own c_ (-11-A--- ,C.1 a-.ci la 0 o
MAILING ADDRESSE-MAIL
CONTRACTOR 1...10'1 3 (7.i BS O,1 1"p
_L,' /2-08 0 rPzS lam`�- Lis h J
CITY STATE ZIP FAX (,_C f`"I
evt> Z.ciLi-A r 2 2 Q L( 41-'3.— 3 S13 - y 5-q L
WA STATE CONTRACTOR'S LICENSE# EXPIRATION DATE FEDERAL WAY BUSINESS LICENSE#
/ / .Z..0'' 6 t istwitt-co-6L
NAME PHONE
S p.1.-^-Q "AsS (cv.1-ii2A-crt (L
APPLICANT MAILING ADDRESS E-MAIL
CITY STATE ZIP FAX
PROJECT CONTACT NAME PHONE
(The indivirlunl to receive and ia'C'3 V Au(c%4 IJ 40"7-44 0 ..') 0(3
respond to all correspondence MARLING ADDRESS CC pp ✓� E-MAIL-concerning this application) i 1 6J O.+^ 1� %2..t3 a f Pr S E' 4-tr-z
CITYSTATS
1J £v FAX rc M
ALTERNATE CONTACT NAME: PHONE E-MAIL
Dps1 L c. M.442s 2(4)11' (c,• PAve c r.ei.5Cair1pr
PROJECT FINANCING NAME
('0M
Required value of$5,000 or more ) 6 El OWNER-FINANCED
(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: DATE "'AA
PRINT NAME: WC'13 V A)j, -I I
Bulletin#100-January 1,2011 Page 1 of 3 k:\Handouts\Pennit Application