14-105544 RIVED
CRY OF A *CT 2 3 2014 PERMIT.IPPLICATION
Federal Way
y
333,25" � � e g' OF CDS FEDERAL WAY i1fig' Areze tL461i +
.--- 44-
PERMIT NUMBERJ 4-- — - [ / G 6Q -i6 TARGET DATE
SITE ADDRESS SUITE/UNIT#
3,3 C �c / Y5Dc 7 _
PROJECT VALUATION ZONING / ASSESSOR'S TAX/PARCEL#
TYPE OF PERMIT ❑BUILDING PLUMBING 0 MECHANICAL ❑DEMOLITION 0 ENGINEERINGiRE PREVENTION
NAME OF PROJECT .D i-a Mat 7 f e C ker
PROJECT DESCRIPTION �
Detailed description of work to 4 €�p-FJ' i C ' >-S
be included on this permit only
NAMEPRIMARY PHONE
PROPERTY OWNER IA a- MA /VI V es -1.
MAILING ADDRESS E-MAIL
CITY STATE ZIP
NAME PHONE
MAILING ADDRESS
CONTRACTOR gd fh S-74. .n - or 0, .. .i i' - _ 'a . ' 4041
CITY ••// PP STATE/ , ZIP FAX S IV
WA STATE CCONTTRAC"I OR'S LICENSE# �'�/Q ��EXPIRATION IOE FEDERAL WAY BUSINESS LICENSE# CO
iinert-TP pr p a q .00 w i 31 /S' 1041.->o14,6?a_ov-,rte.
NAME CJAn4jr - PRIMARY PHONE
APPLICANT MAILING ADDRESS EMAIL
CITY STATE ZIP FAX
NAME
PRIMARY PHONE
PROJECT CONTACT ,p Q c{_�(,/{"1 / /'r 77 67/-,?cd
(The individual to receive and MAILING ADDRDCB E-MAIL
respond to all correspondence
concerning this application) CITY STATE ZIP FAX
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 t ity as a part oraeis a iication.
SIGNATURE: '_ � DATE
PRINT NAME: I / 14
Bulletin#100-January 1,2013 Page 1 of 3 k:\Handouts\Pernut Application