15-101351 1466
CRY OF PERMITTAPPLIO ON
Federal Way
MAR 1 9:.2015
PERMIT NUMBER I 1 0L 3 S t _ FPCITY OF FEDERAL WAY
TARGET DATE CDS
SITE ADDRESS SUITE/UNIT#
7)391-S- 751--
-
LiA/ C=C Ex't_1�_ 7 �-J Sv,�-c- 206/
PROJECT VALUATION ZONING ASSESSOR'S TAX/PARCEL# 0
c l
TYPE OF PERMIT ❑ BUILDING ❑ PLUMBING ❑ MECHANICAL ❑ DEMOLITION 0 ENGINEERING(FIRE PREVENTION
NAME OF PROJECT •
PROJECT DESCRIPTION \>J-> �� N'• ' o--t
~I LR-C-t u.k) (c2 T c
Detailed description of work to
be included on this permit only
NAME PRIMARY PHONE
PROPERTY OWNER 4, c;— , > z--
MAILING ADDRESS E-MAIL
5/ir 4✓A-y
CITY STATE ZIP
re-De x G . y t�/� 955
NAME PHONE
MAIILI��NG ADDRESS E-MAIL
CONTRACTOR ' 5� � i G( Rr7 AJ -c_
CITY STATE ZIP FAX
W STATE CONTRACTOR'S LICENSE# EXPIRATION DATE FEDERAL WAY BUSINESS LICENSE#
(/0-c' � � sS�C ,/ rcp i /(p //5 Iq- 0 - , "y- uS--6(-
NAME PRIMARY PHONE
�/g-e- 5y5 ie-ATS Z✓c`C1-_ 7 5-V3-)zy-g
APPLICANT MAILING ADDRESS / E-MAIL
706
OG,t, 7 -C .- lZ 5'i'TZ-— C
CITY STATE ZIP FAX
NAME �,� PRIMARY PHONE
PROJECT CONTACT //L¢ IT (14'�C/"Y'/-� Z 5 j 7 S / 6^0vS
(The individual to receive and
MAILINGADDRESSE-MAILfVfj�•7�tF O��'��SSS jtIyfff(--
respond to all correspondence L/SHIP I rt�/ -/&_. CD 4, 6,0'1
concerning this application) CITY � STATE ZIP FAX
1 �F-c IFtC- L/(4- -7 6-04-/
NAME
PROJECT FINANCING C/P6--K/L, Se"/L--PCSS ❑ OWNER-FINANCED
Required value of$5,000 or more MAILING ADDRESS,� CITY,STATE,ZIP ��/ q PHONE
W
(CC79.27.095) %Vet /11/Z:771, 444 /(3 .>'-
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 t- reliance of the city, including its officers and employees, upon the accuracy of the
information supplied to the c' as a pa •f t application.
SIGNATURE: DATE y2
PRINT NAME: /4",--
'A ( t-t-/1 01.<
Bulletin#100-January 1,2013 Page 1 of 3 k:\Handouts\Permit Application