14-101589 REceIvED _
Federal Wa PERMIT SF MF CO ME PL DE EN FP
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PR 0 8 2014APPLICATION
COMMUNITY DEVELOPMENT SERVICES
253-835-2607•FAX 253-835-2609
<<,:.',.rn.,;oi!ed m.OF FEDERAL WAY
CDS
SITE ADDRESS SUITE/UNIT#
3S /00 Erck4ed P& wa X S,
PROJECT VALUATION ZONING ASSESSOR'S TAX/PARCEL#
$ lea, A'! 21 126 0 - d / eO
TYPE OF PERMIT ❑BUILDING ElPLUMBING ❑ MECHANICAL
❑ DEMOLITION ❑ ENGINEERING XFIRE PREVENTION
NAME OF PROJECT //./4/ ��
(Tenant Name/Homeowner Last Name)
GI a(-IC p rt fit. $/)(-AI) te_rf A, 'co I otii e
PROJECT DESCRIPTION 1 i
Detailed description of work to fepla4- re,v O-/'e C dIC e srsf'%'j ro Cii
be included on this permit only
NAME PHONE
PROPERTY OWNER noS+CO 41ZS�Y30 gr/c 6
MAILING ADDRESS - E-MAIL
??/ 1-41e-e drl+e
CITY rsxce,(.....4.
n t.i \ S�/IQ� Z 1 Q 2
7
NAME P►^)f '� SYS 1 2 3 `t 2 / 8' d
MAILING ADDRES F{,MAIL
CONTRACTOR (/o6 eft`'Ave ,/oil enir&SY's#714ie ie,eivoi
FAX
Cre,coe.etitu\ STATE44- 8'`'2y t-s3 926 2...3SO
' WA STATE CONTRACTOR'S LICENSE# EXPIRATION DATE FEDERAL WAY BUSINESS LICENSE#
SM,Vr f FS 131So 7 1/ `/v z tti 19-V7-0
oaoSJ-On9i.
NAME A PH
oh A �V —Sfrvilfkie! � PHONE
a- ' 2 /
S9
APPLICANT MAILING ADDREs E ILA Y @SV 1irllTl�'7�)1°,C0.1
CITY t-V STATE ZIP FAX
Z5� 17.z 2-J5 C.)
PROJECT CONTACT NAME 0; r"-C .S T
I,P(D14, /cb A a ,P— PHONE
(The individual to receive and
respond to all correspondence MAILING ADDRESS E-MAIL
concerning this application)
CITY STATE ZIP FAX
ALTERNATE CONTACT NAME: PHONE E-MAIL
N;K/( verve ZS3_v�-$ 8 „,teet'nv@sr+��1141I e 7
PROJECT FINANCING NAME ❑
OWNER-FINANCED
�
Required value of$5,000 or more ly/�
(RCW 19.27.095) MAILING ADDRESS,CITY,STATE,ZIP 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 supplied to the city as a part of his application.
SIGNATURE: (fig" ///P DATE 171-8..-//
PRINT NAME: JoZ .\ Pe1-4 e-Ere!--d
Bulletin#100—January 1,2011 Page 1 of 3 k:\I-Iandouts\Permit Application