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15-104113 RECEIVED 411116, CITY OF AUG 1315 PERMIT PPLI CATION Federal Way CITY OF FEDERAL WAY CDS / �j PERMIT NUMBER / 5 _ 70 7 / �5 _ FP TARGET DATr SITE ADDRESS .•••JJJJ / ✓ �� SUITE/UNIT# C3 �g 336,..(4.„3..„....,z0L -,i-v D PROJECT VALUATION ASSESSOR'S TAX/PARCEL# TYPE OF PERMIT ❑BUILDING 0 PLUMBING 0 MECHANICAL 0 DEMOLITION 0 ENGINEERING FIRE PREVENTION NAME OF PROJECT .• ` ;4_4, / PROJECT DESCRIPTION � pp, Detailed description of work to 'F-1M. l 1�- < \ cb r la, be included on this permit only NPRIMARY PHONE PROPERTY OWNER cx�\ L, C�, MAILING ADDRESS E-MAIL CIT STATE ZIP ,z`�cCGA �J/. ISA 97003 NAME P ONE eA56r• rl.,e��`;c- ;a3-1-15a.5 MAILING ADDRESS E-MAIL CONTRACTOR CITY,., o c�.C) c�J1vC �iCj �(} gn lcio„-0e15rn4�C •t c�1 �.� fT� STATE ZIP F WA STATE CONTRACTOR'S LICENSE# EXPIRATION DATE FEDERAL WAY BUSINESS LICENSE# NAME / / PRIMARY PHONE e")Lt,ivlt+ CL5 (.on�cct.c..vp (" APPLICANT MAILING ADDRESS E-MAIL CITY I STATE I ZIP FAX NAME __,., PRIMARY PHONE PROJECT CONTACT cv\ f L 1- lo6-5a3- 1,/5 J-5 (The individual to receive and M ILING \"�DRESS E-MAIL respond to all correspondence �--V ��AD.4) Std ,1e_ , S,} ate\ P\\`(- "a-66._©� ^' concerning this application) C1TYG��T I E I Zip U10-3 FAX Q dt Lk- PROJECT FINANCING NAME (� 0 OWNER-FINANCED Required value of$5,000 or more MAILING ADDRESS,CITY,STATE,ZIP (RCW 19.27.095) 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 supplie the city as a part of this application. SIGNATURE: DATE `I-3—1 0\ 5 1.--- :-....9.1 . PRINT NAME: f I k:. dl<d tulletin#100—January 1,2013 Page I of 3 k:\Handouts\Permit Application