09-101678 � - t l � _t
g-: SW CO ME EL PL DE EN�P
Federal
ERMIT �
co D o1 s2 AY 0 6 z PPLICATION ' �-
253-$35.2807•FAX253.835-2609
WWII,cltuoffederalwau.com
SITE ADDRESS y CDS
33 ,5Q ( t 1 vE �v I ir-E /0 0
sUnW/m ®U i A King 'iRescue ci ASSESSOR'S TAX/PARCEL#
Approved -
s Dela ted PR :C '
Ca�6ptiougoTittached dot Is ,n _
(Tenant or Ho IeQ1�Ierr Name) N PT U 14 A•_ Pi EA -t (-I- -E[P JT
By
n Z -1 11-PLUMBDIG 0 MECHANICAL
TYPE KtrE MIT j _7 _00e❑ DEMOLITION ❑ ELECTRICAL 0 ENGI EERING/FIRE PREVENTION
F 12€ Y-t aArZ v-\ —TE N AN1 --=w\pcz_ave E.N7
PROJECT DESCRIPTION
Detailed description of work to
be included on this permit only 4y1' E Pe.�,V !� O G _ 1013 zkf — O ) - ( , Od j0„. ..1/4.
a `►�
PEOPLE
NAME PRIMARY PHONE
PROPERTY OWNER (..)1\36€,--t-' 1_; ( ) -
MAILING ADDRESS,CITY,STATE,ZIP E-MAIL
12t 5vel tMoffI` soci S c 24x0
OWNER IS ALSO: 0 CONTRACTOR ❑ APPLICANT 0 PROJECT CONTACT
NAME A PRIMARY PHONE
RIA4e-r (i0 v(b S6(.v(2,t1/ TKL (Z53 ) 75-I - 73/:(o
CONTRACTOR
MAILING ADDRESS,CITY,STATE,ZIP FAX
170 o)c, 9?) RA..1C,1119 %371 ( 3 )meq - /376
WA CONTRACTOR'S LICENSE# EXPIRATION DATE FEDERAL WAY BUSINESS LICENSE#
c. 1244 5ocabP J b I ib tb 7o -0z-iovei -co a,
NAME PRIMARY PHONE
APPLICANT 5 A,M,c ( ) -
MAILING ADDRESS,CITY,STATE,ZIP FAX
( ) -
PROJECT CONTACT NAME PRIMARY PHONE
(The individual to receive and SiC3 r- (X.- CO (z53 )565-- C S 4(
respond to all correspondence MAILING ADDRESS,CITY,STATE,ZIP FAX
concerning this application) 73(.5o c 1 r- 0..eID r -ZZ ( 253)5o4 - 1529
ALTERNATE CONTACTPRIMARY PHONE E-MAIL
vnivs
4eni 1 tc•-(--< ( )q8%7 c)e ' Sz lQ . wv`A
PROJECT FINANCING NAME
0 OWNER-FINANCED
Required for projects with
value of$5,000 or more MAILING ADDRESS,CITY,STATE,ZIP PRIMARY PHONE
IRCW 19.27.095)
( ) -
I certlfj under penalty of perjury that I am the property owner or authorised agent of the property owner.I certijy that to the
best of my knowledge,the information submitted in support of this permit application is true and correct.I certify that r will comply
with all applicable City of Federal Way regulations pertaining to the work authorised by the issuance of a permit.r understand that
the issuance of this permit does not remove the owner's responsibility for compliance with local, state, or federal Iowa regulating
construction or environmental laws.
Ifurther agree to hold harmless the City of Federal Way as to any claim(including costs,e:pennm,and attorneys'fees incurred
in the investigation and defense of such claim),which may be made by any person,including the undersigned, and fled 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 applicattioon.� q
SIGNATURE: L--1' DATE 5 '1 ' i
PRINT NAME:
D..11...:..411 M A h1 harm D......1 ...FA L.\iL...A..s..\D.......:� A....1:...,..,,,