13-104259 _2_ ----Ar c OF A •
Federal Way PERMIT MF CO ME PL DE EN
COMMUNITY OEVEPIdENSTICS APPLICATIONFAX
www.cituolTederalwau.com
RECEIVED 171 , a
SITE ADDRESS SUITE/UNIT#
‘.7;4N-7 log, T`- SEP 2 5 2.013
LN►AY
PROJECT VALUATION ZONING ASSESSOR'S TAX/PARCE�
I003C S r — — —
TreEr OF PERMIT
❑ BUILDING ❑ PLUMBING 0 MECHANICAL
0 DEMOLITION 0 ENGINEERING 0 FIRE PREVENTION
NAME OF PROJECT
(Tenant Name/Homeowner Lost Name) 6 ra Aj f- r:. �, eic•r 1 qun f
PROJECT DESCRIPTION
Detailed description of work to Traxiclyt 14-- (,v/ A- "`. y- ,(,,
be included on this permit only
NAME PRIMARY PHONE
PROPERTY OWNER 13pj' (32-4(f—
&-r
USP+-53)
7 c..,--3—'3..3
&PC `) 52—7E-MAIL
«r - STATE ZIP
-j ia77 TSL
NAME PHONE
CONTRACTOR (,'/ rlc v' )Y. �rAII.
TIThAla STATE UP 9 O o�J F.AX
)J ce O �7YY�
WA STATE CONTRACTOR'S LICENSE# EEPIItATDON DATE FEDERAL WAY BUSINESS LICENSE#
'' ((L( AS f 2-WS / i C) / Kt° .
NAME PHONE
APPLICANT MAILING ADDRESS EMAIL
CITY
STATE 1 ZIP FAX
PROJECT CONTACT mumPHONE
(The individunl to receive and '1 OA nri'q kny24 )
respond to all correspondence MAILING ADDRESS E-MAIL/oncerning this application) Krait(( E-(--
CITY
CITY I STATE ZIP FAX
ALTERNATE CONTACT NAME: PHONE E-MAIL
PROJECT FINANCING NAME
Required value of$5.000 or more 0 OWNER-FINANCED .--,
(RCW 19.27.095) MAILING ADDRESS,CITY,STATE,ZIP PHONE
I certify under penRlty of perjury that I am the property owner or authorized agent of the property owner.I certify that to the,best
all knowledge, the information submitted in support of this permit application is true and correct.I certify that I will complyiwith
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 owners responsibility for compliance with local, state, or federal laws regulating
construction or environmental laws.
'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�applllication.
SIGNATURE: �� F'�ti1' C it- �—• DATE
PRINT NAME: t 4 r^ G(/Li' (_:
Bulletin#100—January 1,2011 Page 1 of 3 k:\Fiandouts\Permit Application