12-104450 ECEIVE® • - �- 5(:),deral Wa PERMIT
SF MF CO ME PL DE EN P
2 APPLICATION
s 2012 \
COMMUNITY DEVELOPME 3R CES ■ N
-ATI O
253-835-2607•FAX 253-835-2609
Ci(itO(kdenliWOU.M11,,FEDERAL W
CITY or
CDS
SITE ADDRESS SUITE/UNIT#
3G S 0 (a-r� E Due u g
PROJECT VALUATION ZONING ASSESSORS TAX/PARCEL#
TYPE OF PERMIT CIBUILDING ❑ PLUMBING ❑ MECHANICAL
❑ DEMOLITION ❑ ENGINEERING FIRE PREVENTION
NAME OF PROJECT /� p
(Tenant Name/Homeowner Last Name) \UT"W�L c�- �AJ S v A rJ C 1 1
PROJECT DESCRIPTION k.6 SP(2.--/•J l t✓I�
Detailed description of work to �/A-A4001-
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be included on this permit only
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(0)
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NAME PRIMARY PHONE
PROPERTY OWNER Vn/l F ��dCo Gn i \Z04,) } ` �eA 0
MAILING ADDRESS %01) II"J'Jit 5 E-MAIL`
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CITY STATE ZIP
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NAME PHONE
Drlr2 C� E-MAIL
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RES
CONTRACTOR
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CITYSTATE ZIp
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WA STATE CONTRACTOR'SR'SLICENSE# EXPIRATION DATE FEDERAL WAY BUSINESS LICENSE#
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NAME
ONE
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APPLICANT MAILING ADDRESS E-MAIL
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CITY STATE ZIPRtAL
PROJECT CONTACT NAME PHONE
(The individual to receive and v� 44 4 A()el_`G�'v
respond to all correspondence MAILING ADDRESS E-MAIL
concerning this application)
CITY STATE ZIP FAX
ALTERNATE CONTACT NAME: �} PHONE E-MAIL
e•,:kr'k, 6.L. j(t /-
PROJECT FINANCING NAME
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 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. /
e //2_SIGNATURE: -jj Z DATE c9
PRINT NAME: -re
Bulletin#100—April 14,2010 Page 1 of 3 k:AHandouts\Permit Application