14-101700 RECE •
APR PERMIT APPLICATION
Federal Way 1 5 2014
CITY OF FEDERAL WAY
PERMIT NUMBER / Cps, / 7 0 V - F
TARGET PATE
SITE ADDRESS SUITE/10MT S
'35/00 (ivctMA-(77rD "A/2/(6)AY goOTWW
PROJECT VALUATION ZONING ASSESSOR'S TAX/PARCEL•
$ 3/017 A / A6 0 - eTYPE OF PERMIT 0 BUILDING 0 PLUMBING 0 MECHANICAL ❑DEMOLITION 0 ENGINEERING/FIRE PREVENTION
NAME OF PROJECT ` l ) '�c o
PROJECT DESCRIPTION ` � lrii/.'(v'0 A.o SSU i, Lf/s a/I/o.(J �U,4,"aLT/d2
Detailed description of work to J'1�]�1!f?�) �y�/ �i�YJ i s A Lb Olt/L 7u/- Sy jrri/gi
be included on this permit only F 6A/JOA) TANA 1/2071-C75.4.39 Ou rk) .4ti O
//b'--i(AA-tm ) "A,27-677A? //A-A1 U1r't 9' 'aver-
NAME PRIMARY PHONE
PROPERTY OWNER la 5 re o
':3 ADDRESS
-.,JC tHAA1i2'019A16,)yE-MAIL
STATE ZIP/
,AAA .e r AAJo 5"/17(rT% )NG 06 Z Fid-17 Z
MAMING ADDRESS ^ E-MAIL
CONTRACTOR 3C/3 3e0 ' aL ° •
CITY STATE� �/t a 41,4 41,04
FAX
A STATE CONTRACTOR'S LICENSE I EXPIRATION DATE FEDERALWAY BUSINESS LICENSE#
AAA fm's 2 Novi / i i/ Z /a/663-0o -BL
PRIMARY NAME 5'r� 1, - _Trrlo/tIZ1L. 2 ZOZ-7Zr3 Cf
APPLICANT
MAILING ADDRESS
✓! CJ e AA �� •C a"y/
CITY STATE ZIP FAX
✓///4
NAME PRIMARYPHONE
PROJECT CONTACT Sr2%
(The individual to receive and MAILING ADDRESS E-MAIL
respond to all correspondence
concerning this application) CITY STATE ZIP FAX
PROJECT FINANCING NAea 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 authorised 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 authorised 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 • •,It •
8IGNA ": DATE 1/"-/Z —/G/
PRINT NAME: i' -- /SO
Bulletin#100-January 1,2013 Page 1 of 3 k:\Handouts\Permit Application