15-104425 0 •
aTyce PERMIT APPEgUA QON
Federal Way
SEP 01 2015 3"53
( {-� /L /lam �J 5--
I - rpCITY OF FEDERAL WAY
PERMIT NUMBER lJ `� `-1' (i CDS
TARGET DATE
SITE ADDRESS SUITE/UNIT#
3 / 5d-q - 1irk PL 5tJ Feder GJf ei4 q 3 leo - /S"
PROJECT VALUATION ZONING ASSESSOR'S TAX/PARCEL#
$ (030
6-.
655 7 O 0 - 0 ! ? O
TYPE OF PERMIT ❑ BUILDING ❑ PLUMBING ❑ MECHANICAL ❑ DEMOLITION ❑ ENGINEERING FIRE PREVENTION
NAME OF PROJECT / v r LA-K,L Wt- IS
PROJECT DESCRIPTION
II'�St-aite, tr/n1 or 5pnht`l.er 5SIe#.11I114pc 13 1) , Ih
Detailed description of work to re 5,den net( ►'Le IA) CYLS1 ru c-t'On .
be included on this permit only
.---- ---- NAMEFI PmQ,,� C rV1 ih_V LC+¢.� PRIMARY PHONE,/-
PROPERTY OWNER t I e— US.4 LLC- t'OwS) q -tiEY -4.tD o2.?
MAILING ADDRESS n u,0�r (�► {�-�
j1i0- 113.- , v� N� 4 4-0.2-
CITY ieV S'r TE ZIP
C_ ►, 8v0
NAME ^�`(R � P) ` PHONE
,r;1
CK LA-114-be-e- * Co rho-- 053-g7-/v-39
MAILING pRESS E-MAIL
CONTRACTOR De) -79 a- clodj@ @ ri c,rthe plwmbae.,.com
CITY " `� - ' STATE ZIP.61'i 3 3 8 FAX
-$1440-31 37
WA STATE CONTRACTOR'S LICENSE# EXPIRATION DATE FEDERAL WAY BUSINESS LICENSE it
Rte.K.PC..L KA/ 5i i5 /Zoit. , .-11-1O51ot0-0o-aL
NAME r PRIMARY PHONE
C44- _ CL �h
"A-eS OU e.1
APPLICANT A
MAILING ADDRESS JJ E-MAIL
CITY STATE ZIP FAX
NAME \',y1,{1 , �� (� �n PRIMARY PHONE o,
PROJECT CONTACT 4JocL Th 'di�t' 1 53-S ,-,`�3 I
(The individual to receive and MAILING ADDRE
E- \\
respond to all correspondence PO --19 a'-' abuv
concerning this application) cIIYC , ZIP8-33g FAX
vY(ti I1N if
NAME
WNER-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 supplied to the city as a part of this application. /
SIGNATURE: 9U2 - `ya' DATE q / i //‘
PRINT NAME: CE4 j I t.uvLbJ1 r] _
Bulletin#100-January I.2013 Page 1 of 3 k:\Handouts\Permit Application
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