17-100914 • I
f_ PERMIT APPLICATION
Federal Way
PERMIT CENTER+33325 8th Avenue South+Federal Way,WA 98003-6325
IIIIIL
253-835-2607+FAX 253-835-2609+perrlanederalway.com
PERMIT NUMBER _ I. 0 0 c9 ( � _ � FEB 2 4 017
_ _ TARGET DATTmE
6O
SITE ADDRESS SUpiiIT#
!SOT' s 'maw ST TetEMPrL W Ay WA
PROJECT VALUATION ZONING ASSESSOR'S TAX ARCEL# 0 er,/
TYPE OF PERMIT ❑ BUILDING 0 PLUMBING 0 MECHANICAL 0 DEMOLITION 0 ENGINEERING'CARE PREVENTION
NAME OF PROJECT ECONCI L.-00C-ire
PROJECT DESCRIPTION
Detailed description of work to 'EJPt.AtE TrI LAN PAr4E-- V•l/ SIL Sac>15
be included on this permit only
NAME PRIMARY PHONE
►V\J F4 S p„N'C>.4A ((RCS) is-ss • o
PROPERTY OWNER MAILING ADDRESS E-MAIL
iSDS S• 4-ya ZSST I gY ( Mt •CAS M
CITY STATE ZIP
'€.Q.AL b4'j w►A 9tt503
NAME PHONE
CinsTAS c*z.c 9 010,Calan 1 (963) S Ca•i%a
MAILING ADDRESS E-MAIL
CONTRACTOR 3 SPo .wlc YAt.L.cy }Iry N•
CITY STATE ZIP FAX
Autyua n1 `x`414 4 too I
WA STATE CONTRACTOR'S LICENSE# EXPIRATION DATE FEDERAL WAY BUSINESS LICENSE#
ONE
NAME I IC. . MAG,Artpy lav v) t• ikib
APPLICANT MAILING ADDRESS E-MAIL
&Sao W£r VALLEy Al lvy N• MAIrPtif MtQ c wrys•c OM-
CITY STATE ZIP FAX
PwauQaJ 'NA groat
NAME _ - PRIMARY PHONE
PROJECT CONTACT 'l 5 4X., AS P PPUc.ro► i' ' 4•
(The individual to receive and MAILING ADDRESS E-MAIL
respond to all correspondence
concerning this application) CITY STATE ZIP FAX
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.
SIGNATURE: 0144( DATE a'•10•
PRINT NAME: Mila M46,19nrAy
Bulletin#100—January 29,2016 Page 1 of 2 k:\Handouts\Permit Application