12-104685 l?--
•
- / ® ( L5
CITY OFOAR
RECEIVED PERMIT SF MF CO ME PL DE EN-'
Federal Way
COMMUNI7Y DEVELOPMENACII 1 2012 APPLICATION
253-835-2607•FAX 253-835-2609
www.cituorrederut.ro
ITOF FEDERAL WAY L (r U U UU U�)
CITY CDS
SITE ADDRESS SUITE/UNIT#
33C I,- G1( S . (90
PROJECT VALUATION ZONING ASSESSOR'S TAX/PARCEL#
$ 3.91-i6-°Q q s 0 - n 5- Q
TYPE OF PERMIT ❑BUILDING ❑ PLUMBING ❑ MECHANICAL
❑ DEMOLITION ❑ ENGINEERING 1KFIRE PREVENTION
NAME OF PROJECT
(Tenant Name/Homeowner Last Name) V r^ 1 D r( � e
PROJECT DESCRIPTION ivro& iilf) Emend 504,9- dh I . Id 9L s ve cAel°L )
Detailed description of work to 3 ho �. 664060 . Cd1L1eC4- � t.51•l r/ICI t.
PObe included on this permit only _WE(' 50
J
PROPERTY OWNER NAME i 1,L L► M U c.1T-1\\/`
1 f\`r` cp. PRIMARY PRONE
MAILING ADDRESSE t of �'•IcVV�1c I lllf tin' 12C(•• E-MAIL
CITY W\404.56(\ TY7 T. ZIP 6370
V I
NAME \, 'CtShinc1 Alarm Piga- 325- SOW
DRESS r- E-MAIL
MAILING�
CONTRACTOR /?a�3 S. JGcI/sOrt ��. rnmLti1rdi%§t,xs\,on\6ne.lurn•cow
CITY N'' Nk `/'�1/Q 144 ` FO " aQ r�V 11 1
WA V/rAzg rl:1A 1. s2#C2 U� o EXPIRATION i Tl3/ PV 00 A I VI_ FEDERAL WY WI S-CO eA A,
NAME
Lark Mk/Z.,'0 P_Ob'
APPLICANT "Gj MAILIDan 5 `5„_(iso C�..�- Mmd I(Ain&thr, 1114 (Am
CITY
SeliCl Ite YT�1` ZipciV I 1 FAX a399-ria IL4
PROJECT CONTACTlPHONE
NwME
(The individual to receive and /me G.S Vrt.ci 4
respond to all correspondence MAILING ADDRESS 1 E MAII
concerning this application)
CITY STATE ZIP FAX
ALTERNATE CONTACT NAME: PHONE E-MAIL
PROJECT FINANCING NAME
0 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 cert fy 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: j� !'�,-/ i��� � _ DATE 10- //-21/
PRINT NAME: Owls f l' C I.Jc.to
Bulletin#100—January 1,2011 Page 1 of 3 k:\Handouts\Permit Application