14-100654 • •
CITY OF PERMIT APPLICATION
Federal Way ReCEIVED
4 �4 Fp. FEB 11 2014
PERMIT NUMBER I r p A
-
TARGET DATE CITY OF FEDERAL WAY
-
SITE ADDRESS SUITELLTID j#
49001 J\\LA 'e D S
PROJECT VALUATION ZONING ASSESSOR'S TAX/PARCEL#
$ 5200 n L\ .z 1 0 4 - 9 D 3 1
TYPE OF PERMIT ❑ BUILDING 0 PLUMBINGJt.0 MECHANICAL ❑ DEMOLITION ❑ ENGINEERING FIRE PREVENTION
NAME OF PROJECT P` 2 i
.
2J,v\
PROJECT DESCRIPTION ' k)s�LL_ AK)s A L LA Q 21/A1-4000
_ '3C rk yz__F
Detailed description of work to �P L SS(O Q j`t)STC1 ' I i 1 1 i 2 LJfi
be included on this permit only .. ( €id Rc 0
NAME
PRIMARY PHONE
PROPERTY OWNER
MAILING ADDRESS E-MAIL
CITY STATE ZIP
NAME
PHONE
(V-P►tJE Cit£ 3L90--SS-S4ILN
MAILING ADDRESS E-MAIL
CONTRACTOR Pn 6OY 7(o 5 c'---1-512 F 1 iNl-PItoCE119 .Cllr
CITY STATE ZIP FAX
gtAlzLt kxn-lt ISA 91,32.__ 3(ao•-t35-so IS
WA STATE CONTRACTOR'S LICENSE# EXPIRATION DATE FEDERAL WAY BUSINESS LICENSE#
I SP 1 1 i • / Z) -V - P *al - •• --..eiL
`NAME\ /� ,/� � PRIMARY PHONE
IV��VA 1 i A'Q'J/'''q I?
APPLICANT MAILING ADDRESS E-MAIL
SCV 1F_ RS ACAJE
CITY STATE ZIP FAX
NAME PRIMARY PHONE
PROJECT CONTACT
p‘
PROJECT CAT-
(The individual to receive and MAILING ADDRESS E-MAIL
respond to all correspondence
concerning this application) CITY STATE I ZIP FAX
NAME OWNER-FINANCED
PROJECT FINANCING
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 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 suppli • o the city as a part of application.
I ,‹-ej
I -7
SIGNATURE: \\_)_� `A // 1 DATE I l t o
PRINT NAME: V \F\ TINY( _01?----
111
Bulletin#100-January 1,2013 Page 1 of 3 k:\llandouts\Permit Application