11-102391 301 I
CITY OF
PERMIT SF MF CO ME PL DE
Federal Way
5
COMMUNITY DEVELOPMENT SERVICES APPLICATION J(I N 1 7 2011 p
253-835-2607•FAX 253-835-2609
www.citii� 1cralwau.com
1 OF ren
ORAL WAIS
SITE ADDRESS C „-1UNIT#
•
PROJECT VALUATION ZONING ASSESSOR'S TAX/PARCEL�6 � � - � /
$ a740�
3 0
TYPE OF PERMIT ❑BUILDING ❑ PLUMBING ❑ MECHANICAL
❑ DEMOLITION ❑ ENGINEERING ..-FIRE PREVENTION
NAME OF PROJECT
(Tenant Name/Homeowner Last Name)
PROJECT DESCRIPTION '�Nf f 11I ' ' - 4.44 '!' 57"e-41-•- P ` � /- c'z.
Detailed description of work to E I 41 Y'LC
��ijdw►�S
be included on this permit only
NAME PRIMARY PHONE
PROPERTY OWNER !Rd Pefl Apaof�ivu ? 3 /14 - 2
i
f
MAILING ADDRESSE-MAIL
62-3 M lr- .may & •
STATE ZIP
NAME PHONE
CONTRACTOR
MAILING�ADDR ssr` 7 3 2. / ✓�' r1!NNOMS QU 4,1041
C `��V STATE ZIP FAX
1 u /dl I;Li ?S 73 z43-'/Y -/O((
WA STATE CONTRA R'S LICENSE# EXPIRATION DATE FEDERAL WAY BUSINESS LICENSE#
NAME PHONE _.
I r&'-crov
APPLICANT MAILING ADDRESS E-MAIL
CITY STATE ZIP FAX
PROJECT CONTACT NAME L r T ♦ PHONE [� /
(The individual to receive and .'C--Cr 51 ��l kt-est -Act Y��A alk ! G/6 ik6
respond to all correspondence
MAILING ADDRESS �+�_ / E-MAIL
concerning this application) Ste e-614? .
CITY STATE ZIP FAX
ALTERNATE CONTACT NAME: PHONE E-MAIL
PROJECT FINANCING NAME
y OWNER-FINANCED
Required value of$5,000 or more
(RCW 19.27.095) MAILING ADDRESS,CITY,STATE,ZIP PHONE
I certify under penalty of perjury that I am the property owner or authorized agent of the property owner.I certfy 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 • •art of this applic• .
SIGNATURE: Kee
.0DATE
PRINT NAME: / 'v i�
Bulletin#100—January I,2011 Page 1 of 3 k:\l-Iandouts\Permit Application