14-101235 *RECEIVED
CITY OF A PERMIT PPLICATION
Federal Way MAR 18 2014 `b,��
CITY OF FEDERAL WAY
d: c
PERMIT NUMBER / iCr
J TARGET DATE Ji/ (�Z
SITE ADDRESS SUITE/UNIT#
3 2 20 0 Mil( 4-a 1201 S 1 cateA�Q. (,x,4 4/goo oo (
PROJECT VALUATION ZO� ASSESSOR'S TAX/PARCEL*
$ 111050 ► S 2_ l n (-I - `� 0 -
TYPE OF PERMIT 0 BUILDING 0 PLUMBING 0 MECHANICAL ❑ DEMOLITION 0 ENGINEERING Vir FIRE PREVENTION
NAME OF PROJECT J►ii I !i_
C
PROJECT DESCRIPTION i 04 Ce ` 1A G t' r l 6 , r(41e,r- 1 k )3 Fits
Detailed description of work to y D GV W1 l a 4 i?eC, CeAkir
be included on this permit only
N . t PRIMARY PHONE !`
PROPERTY OWNER E,QS1C)) E t�cStae..A�c�� c e�. M 1. x._ /06.2-ZZ -S26C0
�o 1ADDRESS u)�e$v [ Q -IOQ E-MAIL
cTY v �R% 21 F2o6 •282.1\30
PHONE
NtInE1 mss FL re Safe A49114 4d-5. 57D-.3(434
MAILING ADDRESS E-MAIL
CONTRACTOR 3122' 5114'1/4- 01-6(. et 6 t-w'6' '"'CITY
uUcn Le_ (AO— eit6 ZIP FAX
Q Z1-
rodu�
I
WA STATE CONTRACTOR'S LICENSE it EXPIRATION DATE FEDERAL WAY BUSINESS LICENSE It
/1/t$ 9V(C) i Zt / ] if-1 of3- ' --
NAME PRIMARY PHONE
3r�(/V�2 a4 c6 i
APPLICANT MAILING ADDRESS E-MAIL
CITY STATE ZIP FAX
PROJECT CONTACT NAME S , f s &� PRIMARY PHONE
(The individual to receive and MAILING ADDRESS E-MAIL
respond to all correspondence �3 L(ZZ— J cf- -t_ SE
concerning this application) CITY - STATE ZIP FAX
l tOdtI v,I( ( 44- q`"12
PROJECT FINANCING NAME 0 OWNER-FINANCED
Required value of$5,000 or more MAILING ADDRESS,CITY,STATE,ZIP PHONE
(RCW 19.27095)
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.7dtAetAA14, /Li
SIGNATURE: I/\AA4 /� DATE 3 l t r l
PRINT NAME: K r% s 6.1 e_ i!k 0.4.451-e41-
Bulletin
sBulletin#100—January 1,2013 Page 1 of 3 k:\Handouts\Permit Application