14-104947 .k... •
i 1 i-_ - 1 0 4 9. 4 .,7
Federal Way t�PERMIT SF iyPL DE EN %FP
COMMUNITY DEVELOPMENT SERVICES APPLICATION S E P 2 5 L U I L
253-835-2607•FAX 253-835-2609
ww w.citgoffederaiwau.corn
CITY OF FEDERAL WAY
SITE ADDRESS
CDS
suITE/IINIT#
:3 5-1 0 5— Er\c),1AA4C-0( (7t r Kia-] '
PROJECT VALUATION ZONING ASSESSOR'S TAX/PARCEL#
TYPE OF PERMIT ❑ BUILDING ❑ PLUMBING 0 MECHANICAL
0 DEMOLITION 0 ENGINEERING X FIRE PREVENTION
NAME OF PROJECT
(Tenant Name/Homeowner Last Name) ��c , ) 'T- I
PROJECT DESCRIPTION [ n _
Detailed description of work to r i,rte C Y1 {� L....4i'C \ p Gem Cn A1C
be included on this permit only
NAME -
PROPERTY OWNER PRIMARY PHONE
MAILING ADDRESS E-MAIL
CITY STATE ZIP
NAME Ac,
t rz PHONE e
F S 1 C 1---1--C___ —4 k it--c S-73
MAILING ADD E-MAIL
CONTRACTOR 20 > — �G\j« I?Loe 4 C,�a,• Lr�—
CITY g U�C\ STATE ZIP FAX
I
Wk i`vlZ-I
WA STATE CONTRACTOR' LICENSE# EXPIRATION DATE FEDERAL WAY BUSINESS LICENSE#
A-GE '.45-?a OA (2-/ -3\ i V 4-
NAME ... ..- ,_.
PHONE
APPLICANT
MAILING ADDRESS
E-MAIL
CITY STATE ZIP FAX
PROJECT CONTACT NAME
� a PHONE
1� G� �.J �o�1� �4�1-1 f-7(-
c
(The individual to reeive and
2p�r
respond to ail correspE-
ondence M�INGpADDRESS _
concerning this application) T •o {S c.& a.)6.c b u,e1G r-'136 c)i le,,
,,,./._
1
CITE STATE Ct FAX
�CJ PAC' �j��3Z
ALTERNATE CONTACT : PHONE E-MA1L
—
PROJECT FINANCING NAME
Required value of$5,000 or more 0
OWNER-FINANCED
(RCW 19.27.095
) MAILING ADDRESS,CITY,STATE,ZIP PHONE
1 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. Iunderstand 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� ya
/
icity as a part of this application.
SIGNATURE: //-- C"—'-----_---..._ DATE 47- -Co I
PRINT NAME: 45/A 41'e-'4'e"---
Bulletin#100—January 1,2011 Page 1 of 3 k:\Handouts\Permit Application