15-104253 RECEIVE •
«r~o� ` 4 2015 PERMIT APPLICATION
Federal Way AUG 2
CITY OF FEDERAL WAY
PERMIT NUMBER ---)
CDS. �) L� �j ``
LL / ! - �� TARGET DATE
SITE ADDRESS SUITE/UNIT#
5C/ 17 in IL%TA-rc y 2 5
PROJECT VALUATION ZONING ASSESSOR'S TAX/PARCEL#
$ 752 (6 4/ Z ! g6 e/_ 9 0 3 325
TYPE OF PERMIT ❑ BUILDING ❑PLUMBING ❑ MECHANICAL ❑ DEMOLITION 0 ENGINEERING FIRE PREVENTION
NAME OF PROJECT r , /
/
PROJECT DESCRIPTION �57-71-f L _- NJ /t/- 7 I(_'}T1v� ,_X% ,• -is 6,
Detailed description of work to
be included on this permit only
NAME PRIMARY PHONE
PROPERTY OWNER //,4Cir C-A/S
MAILING ADDRESS E-MAIL
CITY STATE ZIP
NAME _ - .- _ _- - PHONE
F" SY5z'rs we s:� /mac 2s7' 5133—/Z`1f�
MAILING ADDRESS E-MAIL
CONTRACTOR 25k5' F20Ac/4r-4G Cr. Viz-;" A/ Sv/Tr-- -(
CII> STATE ZIP/ FAX
i tiC/r-/i_ 4//4" 9 Kc1597
WA STATE CONTRACTOR'S LICENSE# EXPIRATION DATE FEDERAL WAY BUSINESS LICENSE#
fr/Atri= a 5wg e$'L!) jrC / /4 / /Co
NAME - --- - - - PRIMARY PHONE
/4(r 'SJ�7-e174 iS '- i c,/ /I .
APPLICANT MAILING ADDRESS E-MAIL
CITY STATE ZIP FAX
NAME PRIMARYC/PHONE
PROJECT CONTACT /T/ 'T &AA/44/ 253-
^-Corrscm
('!'he individual to receive and MAILING ADDRESS E-MAIL
respond to all correspondence
concerning this application) CITY STATE ZIP FAX
NAME
PROJECT FINANCING 0 OWNER-FINANCED
Required value of$5,000 or more MAILING ADDRESS,CITY,STATE,ZIP PHONE
(RCW 19.27.095)
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 th City of Federal Way as to any claim(including costs,expenses, and attorneys'fees incurred in
the investigation and defense of su• laim), which may be made by any person, including the undersigned,and filed against the city,
but only where such claim a s • t of the reliance of the city, including its officers and employees, upon the accuracy of the
information supplied to the t • •part of this application.
SIGNATURE: DATE ���4/-
PRINT NAME: 447e6+[ 4/ ___
Bulletin#100—January 1,2013 Page 1 of 3 k:AIandouts\Permit Application