17-100836 R. cE
4 fivED
PERMI PPLI ATION
'iii C
Cla, F :,,;. 2011
FEB 21 PERMIT CENTER+33325 8,1,Avenue South+Federal Way,WA 98003-6325
253-835-2607 +FAX 253-835-2609 +permitcenter(a,citvoffederalway.com
CITY OF FEDERAL WAY
CDS
PERMIT NUMBER 1 _ 1 0 0 g 3 w - ! TARGET DATE A) I1 J
SITE ADDRESS SUITE/UNIT#
1-15.6 G\T't Pier e. s ov-rh
PROJECT VALUATION ZONING ASSESSOR'S TAX/PARCEL It
$ 1 �� O? - _5_ a 14 5 - d C a o
TYPE OF PERMIT ❑ BUILDING ❑ PLUMBING ❑ MECHANICAL ❑ DEMOLITION ❑ ENGINEERING XFIRE PREVENTION
NAME OF PROJECT SA . -cj6S \ `. --c c\Z / Ccr' ,^ 1_0,,b1_0,,bb
P-63 0..-1-‘6 COC ck A e 'c.\ -�- \
PROJECT DESCRIPTION P
Detailed description of work to y\e_M) I A X&\ G.,16 c.e,-1 I i (1 C' (_C'1 V\c't 0)U CCA-#-0 Y\S,
be included on this permit only
NAMEpp PRIMARY PHONE
i
PROPERTY OWNER ` . C.cof 6 ISS\''k& \
MAILING ADDRESS E-MAIL
3t45 15 (301# j ve . % ,
CITY STATE ZIP
V'ci ccd L&)a� WR °I'1c003
PHONE
WeM-ex S\o c
teS ..te ?cn- -10c din i --ri\-1-rA 3
MAILING ADDRESS ]/� / E-MAIL f �,(�
CONTRACTOR I `�r)`l0 N 9 th .> • jvi I t l6 1 an Ly�< e IVO G (itiJ?P-
CITY STATE ZIP FAX jJ�
LAA- 9 65Q '- - 8g l3035
-
WA STATE CONTRACTOR'S LICENSE# EXPIRATION DATE FEDERAL WAY BUSINESS LICENSE#
[Ai e—c i' -� c a / 3 ) / 11
aaNIE , PRIMARY PHONE
f-rvi \j S-e r v01(S ?.fib --1`"1 i y 2n
APPLICANT M ILING AD RESS E-MAIL
Coqo s-. v� fi 10 I erni11 rvats�@► 'p.03
re�lrr<) t:1 TAN z �65a FAX
LOS'' S1-1303e
N.AME PRIMARY PHONE
PROJECT CONTACT tin X\\DI e.-vc j S' 23(0---?°l 1 - L--(2.q3
(The individual to receive and MAILING AD RESS E-MAIL
respond to all correspondence ►y1090 KE 66111 SSi - Uft rt 10 e,M1)tI 8 Seco "Sg ils i).0S
concerning this application) CITI4. STATE Zip FAX
YYkOna UJA (11 C.._ 92S-$TO- 3CW
NAME
PROJECT FINANCING ❑ OWNER-FINANCED
When value is$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 the city as a part of this application. j
SIGNATURE: 4,---u,__....--) /� l
DATE d' •-1 6•
PRINT NAME:J !m 1 it J� `.�.e v-\IOi- 1 C
Bulletin#100—January 29,20161 Page 1 of 2 k:Handouts Permit Application