12-104686 102.
A 411 AC - JO cri_6 I ..,,
Federal WWECEIVED PERMIT SF MF CO ME PL DE E Ifo
N
COMMUNITY DEVELOPMENT SERVICES 1 ^ aPP JI CTI
O i
A i
253-835-2607•FAX 253-835-26 CL i
www.cittioffederalwau.com
CITY OF FEDERAL WAY
SITE
S 1 CDS A� 6)-6 lit'ib 1 a SUITE/U10 #
PROJECT VALUATION ZONING ASSESSOR'S T / EL# ,
$ 533
TYPE OF PERMIT
BUILDING 0 PLUMBING ❑ CHANICAL
❑ DEMOLITION 0 ENGINEERING FIRE PREVENTION
NAME OF PROJECT c:ay /1��/f p
(Tenant Name/Homeowner Last Name) Q I� )G `a� rail`+C/
PROJECT DESCRIPTION OMa Oare
CilaSIA 6110M1
Detailed description of work to
be included on this permit only
..
5
PRIMARY
Y PHONE
PROPERTY OWNER NAmESin
IIJ 4,410/4„, VY• ebio
MAILWOOSgtE-MAIL
Vf/ V/le4Q/' d4 _' 31)5
CITY 1/45
SA ZZII
(IVO I
N PHONE C6 _, 425 45
7- 7D
�
7iVb? Cy, s
.g(..k.levV/CONTRACTOR ?4,wile_ 11ZgeD� F4 -Ad--Pt
44
CO OR' LICENS � DATE FEDERAL WAY BUSINESS LICENSE
#
. �a/ % I /
NAME 31�l C
O-1 wed tit 4z -4 7'7cco
APPLICANT MAILING ADDRESS. E-MAIL
Z1DD ;4vdS �bU
C?1W f/
STATE ZIP75-
F
PROJECT CONTACT NAME W'/nJ PHO /64-
0oba
(The individual to receive and
respond to all correspondence MAILING ADDRESS E-MAIL
concerning this application)
CITY STATE ZIP FAX
ALTERNATE CONTACT NAME: PHONE E-MAIL
PROJECT FINANCING NAME
0 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 r-liance of the city, including its officers and employees, upon the accuracy of the
information supplied t, e c' , as a part of .7,1 application.
SIGNATURE: """� , / / /U
DATE ///1
PRINT NAME: , _.1 Al ../ /. /./i __
Bulletin#100-January 1,2011 Page 1 of 3 k:\Handouts\Perrnit Application