11-101633 . :• . RecelAP
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arm RMIT SF MF CO ME PL DE EN7
Federal Way
COALWAU YDEVEWAPMSNFSZR 7 '( Of FED •IDLICATION TA (s v i s o
253835-2607.FAX 253-N5-2608 CI
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luww.dluoffedu.apRA/ µ^y
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SITE ADDRESS
SSGS6 ( r Svc. S . Fectoll way c eoo3 BIIITE,UNIT.
PROJECT VALUATION ZONING ASSESSOR'S TAX/PARCEL I
s 2,9 coo
TYPE OP PERMIT 0 BUILDING 0 PLUMBING 0 PyCHANICAL
0 DEMOLITION 0 ENGINEERING FIRE PREVENTION
NAME OF PROJECT ,_J `T_� /�
�'„ (Tenant Name/Homeowner Last Name) i /V -etAJ 00 d (e,' )'C.l
k , • xis i f EA .P4 N�4C. , -SprI n Kkr Jho t
' . PROJECT DESCRIPTION �+ /��
Detailed description of work to t.. • % L uaJ u 11 S t dAs L _rp olAb Qf'11 _ /
%t_ be Included on this permit only !„ C o vv k_ rt. �l a LL�141 M O/
NAME
ONIS
I PROPERTY OWNER SO i�. I..OM , 2,..0. 51 /'-t i `v
qZ 40O Li( rw, St Ste-I622 Ire 16n6sreolicvs.tom
S 1CITY STATE Z>p
,� Seo v s A 9$10 I , PHONE
l� N SAAAkeg CotAl oki. _ f y So Jhtts 4254 757-7027
CONTRACTOR Rt�,a,-dsT SF . ZiM cs ►1eywotKs•ctoA
LA et-
FAX
tgoso,-00 844
�WA TS CONTRACt'OR'S LICENSE I EXPIRATION DATE ERAL WAY BUSINESS LICENSE
�,cs9zSP1L 7 R �Z,,�-0(410 10-vo-$L,
04 Vcn cr+ai Tr\ADDRESS _ 125-457-7452,7
• APPLICANT La`s Cv�n' v +4f Q "�1e 't
crrr SNJ�'rQ. sa11M FAX wt c
PROJECT CONTACT NAME sAvv .. as WAfriaar�__"`IIr"' ■■ PHONE
�... ' 6 (Tlte tndiD(duat bo reoedle and —
•+� respond to all correspondence "' E
a[ MISCImir►8 this application) - .. - •
CITY STATE ZIP FAX
VA CONTACT NAME: +PHONE EMIL
PROJECT FINANCING NAA
0 OWNER-FINANCED
Required value of*5,000 or mow #
(ROW 19.27.095) IdAHdNO ADDItIi*S,an STATS ZIP PHONE
o - 1
I certify under penalty of perjury that I am thapalpIllty owner or authorised agent of the property owner.I certify that to the best
of my knowledge,the irl.rmation submitted in sumo.a'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 taws.
I further agree to hold harmless the City of Federal Way as to any claim(including costs,expenses,and attorney$'fees incurred in
the inpastigation and de ense of such Ilaim),which may be made by any person,including the undersigned,and flied against the city,
but oat*where such claim arises cwt of the rename;of the city, including its officers and employees, upon the accuracy of the
info:dl/Uon supplied to
SIGNATURE: �� ---
city as a part of th spplicatio
V/7
) - ry�� 13-1(
-
PRINT NAME: . SM 1+
Bulletilt#ROO-January 1,2011 Page 1 of 3 k:Qlandouts\Permit Application