12-104865 f
RECEIVEr' • g C'S
Federal W PERMIT SF MF CO ME PL DE EN 34:1$11QCT 2 4 2012
COMMUNITY DEVELOPMENT SERVICES APPLICATION Y7,11 b
253-835-2607•FAX 2�`3�-'6oF FEDERAL WAY
u;ulu..cihiol(ederu * ,v,Ai rr 1VV E� i
CDS
SITE ADDRESS SUITE/UNIT#
1....5“z0 PAciFic V4\14.'1 SOvT+1,FEFt .M wAl ,NNA 9$003 1301L-i>IN&C.
PROJECT VALUATION ZONING ASSESSOR'S TAX/PARCEL#
9 'i SO, ISO 3 ? 0 - 4 l7 4- Z
TYPE OF PERMIT ❑ BUILDING ❑ PLUMBING 0 MECHANICAL
0 DEMOLITION 0 ENGINEERING 'FIRE PREVENTION
NAME OF PROJECT or
(Tenant Name/Homeowner Lust Name) LPN F\V)\ - PC P? Pc n ` MGN 1 5
PROJECT DESCRIPTION
1ivSTP -LAT(ON OF F i2G N oT%F 1c RTroN 5MSIC-14A
Detailed description of work to
be included on this permit only
NAME A PRIMARY PHONE Q
PROPERTY OWNER LP\ MADE A+7 f MN /F T S •x53 • $39 .2 0O
2.9,6 a)SBPACIfle 14°1 5UvvF1 E-MAIL
CITY STATE ZIP
FePG1-CPrL wilt) w.s 98003 253 _ R39 . 02t9
NAME PHONE
ALA_ VIRE. 1c"-r.1e-. zo6 • 135• 6100
MAILING ADDRESS E-MAIL
CONTRACTOR 3O 31/4k" Sw c kAPSIZI-5,51-O‘ri N 5-t . E12EM1AN.@'�At_1-w\REE'1.r !c•
CITY STATE ZIP FAX GUhn
.5 E PCT"i-L 2_ \,J A 9 8 063 2_06.,935-. 'i-Q b
WA STATE CONTRACTOR'S LICENSE# EXPIRATION DATE FEDERAL WAY BUSINESS LICENSE#
}t(,1....sof4 NI F. 4 6\ CU-- 0 z/z.? 12o'3 20-IN.- 1 0-2.1S-9 -00"-Ig
NAME PHONE
A 1.-Ar \l i \czE; El--V-(717--\c
APPLICANT MAILING ADDRESS E-MAIL
( 5 Anne- AS R6vF)
CITY STATE ZIP FAX
PROJECT CONTACTPHONE
(The individual to receive and NJ E RE M\ M ��Ptv NST N (ALL \,4)2E1 2.0 6.9 3y. 6\ 0 0
respond to all correspondence MAILING ADDRESS E-MAIL
concerning this application) ( 5 Pc MG A S ailov E) 'EV E NA(N4)A LL\r4 R.E ELE o
CITY STATE ZIP FAX
TERNATE
NTACT NAME: PHONE E-MAIL
xrA\Kg..DI. 'AS zo6.931. 6100 M)\.
E.6 A-LLw IRS El-[tT'5.1C
PROJECT FINANCING NAME .CO KA
❑ 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. r�
SIGNATURE: \\4 " DATE- ( 0I AC-0 ()...
PRINT NAME: riklE. L U C io
Bulletin#100—January 1,2011 Page 1 of 3 k:AHandouts\Permit Application