14-101091 • • •
CITY OF PERMIT APPLICATION
Federal Way
RECEIVED
PERMIT NUMBER I el - ( 0U q. f - p MAR 11 2014
TARGET DATE
CITY OF FEDERALcmay
SITE ADDRESS'� 1 S SUITE J
CI s ways Zcp
PROJECT VALUATION ZONING ASSESSOR'S TAX/PARCEL#
TYPE OF PERMIT 0 BUILDING 0 PLUMBING 0 MECHANICAL 0 DEMOLITION 0 ENGINEERING LdNIRE PREVENTION
NAME OF PROJECT l et*A)COA `?)u%lelir J C EPWA J3S)
PROJECT DESCRIPTION A dd I h a/h /c-' .v 1 /✓/' V �+�v .be included on this permit only < ('I )
`� / • f c� 7L�`-C -
.5
NAME - - --- PRIMARY PHONE - -PROPERTY OWNER atgA MI 04-InJeSiMeni lel 1
bl/l;[ G ADDRESS
37 `
_. VIOcA1h teke- W ab St
201 EMAIL
CITrtTATEZIP ^_ O3
eWIe.
NAME
vi -. - PHONE
(1.; (AC* NA.cm�nC 2.136-32s5-32q i
MAILING ADRfE�S t / NAG
} 1-_,,,��'
CONTRACTOR "" O Ac t• ,cJC e •' 1►�1AG 1 WG�h�GaSIII",t" Ca�QN'�vlr1
CIT ki�t STATEZI'To��� FAX
Q t� w�
4CENSE#
/n��w�K'�� •E CONTRACTQ) w e/�, at..I 2.7%riZ 11 /yam
W T/"k J�{ 1^� ,E3 NSE# I �+EXPIRATION
/os- / Il .2.l)`OO-In'(17.9-ESS IC r1
NAME ^A AS A^�� PRIMARY PHONE
APPLICANT MAILING ADDRESS (`•/' l' E-MAIL
CITY STATE ZIP FAX
NAME )�,-�/ t �`-�,,,, �� PRP
PROJECT CONTACT g(�l(, `./ [ T1>CA',\ 2-0 - 3b-E. 533Z
(The individual to receive and MAILING AII/�OW
`, I_ 11,-MOL,
respond to all correspondence hOW �Wf pvt� v' 1 • 061� �'t'td�11.iMt(Qrr
concerning this application) alT l� 4 Y1� 11 \/%1 ZIP \V�„�1, �r FAX
321--92.t4
NAME `�Il `.)-
PROJECT FINANCING ❑ 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 the city as a part of this application. /�
SIGNATURE: . �y/"�l--'.( � `�� DATE 3-// �l/��
PRINT NAME: MV`+ c r" � Ic.t n
Bulletin#100—January 1,2013 Page 1 of 3 k:\Handouts\Permit Application