14-102173 • RECEIVED
CITY OF MAY 12 2014 PERMIT APPLICATION
Federal Way
CITY OF FEDERAL WAY L, 4.50
CDS
/ a
PERMIT NUMBER / V IV ' � � _ —�
vv TARGET DATE
SITE ADDRESS SUITE/UNIT#
o ` W /
PROJECTVALUATION 'N 71....c..) ASSES 'S TAX/PARCEL# 'WO-3
$ ZOO 0I- z ( 04— _ gO -54
TYPE OF PERMIT ❑ BUILDING ❑ PLUMBING ❑ MECHANICAL ❑ DEMOLITION ❑ ENGINEERING AFIRE PREVENTION
NAME OF PROJECT �� U/p.•-( P 5-27A �ZZA - 1.
PROJECT DESCRIPTION G " I o _El, �i5 IA- 'S Y_.)1^- 1-J �
5 t
Detailed description of work to Sci. for T ,L
be included on this permit only
NAME PRIMARY PHONE
PROPERTY OWNER
MAILING ADDRESS E-MAIL
CITY� STATE ZIP
NAME
PHONE
�*-)3 J tQv,/ l� V J IN- ✓YGvr2-OG_ J L I(-1
i 1
MAILING ADDRESS
MAIL /
CONTRACTOR PV t S3� cL.STG-NA-a0�7w"'`-C-
CIT7j,�lJc4411 y/1L
GOAZIP
WV'1 -gloti FAX
W.9,STATE CONTRACTOR'S LICENSE# EX
P-._. 'IZ DATE FEDERAL WAY BUSINESS LICENSE#
M1X77 ]H • /[ S
_ _ NAME
PRIMARY PHONE
I/`c>JS .4-EATS S Z66-30K I qCb
APPLICANT Lo ADDRES E-MAIL
�J'�'il S3 Zev-Si-GNN .rte
CITY STATE ZIP�� FAX
�
5P- w4
. .
PROJECT CONTACT x J `( ` PRIMARY PHONE 4 l c1�
(The individual to receive and MAILLLIINGG ADDRESS�7E-M/(AIIILL��J/O ��(bl��l (��
respond to all correspondence PO 531- 6w•SI'v/"t" ei,..`"
concerning this application) CITY s(AAA TATE ZIPQUS FAX
NAME.5 bPItt
^�/`�
PROJECT FINANCING i' v/A- 0 OWNER-FINANCED
Required value of$5,000 or more MAILING ADDRESS,IIIICITY,STATE,ZIP PHONE
(RCW 19.27.095) ,,,.:r
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 cl•'. arises out of the reliance of the city, including its officers and employees, upon the accuracy of the
information supplied t- -city as a part oft application.
SIGNATURE: DATE S irliq
PRINT NAME: ILtA) -fhwi
`L
Bulletin#100-January 1,2013 Page 1 of 3 k:AHandouts\Permit Application