16-100196 H
CITY Or
PERMIT APPLICATION
Federal Way
0 0 9 RECEIVE)
PERMIT NUMBER I (0 _ ( ' `0 _ Pp A 2016
-
- TARGET DATE
FEDERAL U EAY'
SITE ADDRESS ` l Y C"r
`f 15 1�✓e s' u,/. s t,T
PROJECT VALUATION ZONING ASSESSOR'S TLX/PAR N( a 0 _ � `
TYPE OF PERMIT ❑ BUILDING 0 PLUMBING 0 MECHANICAL 0 DEMOLITION 0 ENGINEERING I+: FIRE PREVENTION
NAME OF PROJECT (I r 1 S " ek rt (,r-`C:I i (1_
PROJECT DESCRIPTION
f‘d1/4a4 r,) )e 5 i n r-,v--e_ 5 r .1 m-vt_c, S r '�Qv✓1
Detailed description of work to 2n S ti,\k C0 vA:4\�. G-ht-e_ k \v^<.--
be
.be included on this permit only
1
NAME PRIMARY PHONE
C_ k0/' I S an. C,-cr lrl5 253-2(eto -21eO
PROPERTY OWNER MAILING ADDRESS E-MAIL
29`i5 /o /WC S -`4
CITY
NAMES,, 5 1/.-`1 I PHONE
--e-`es- 2 3 — tc -–05c03
MAILING ADDRESS EMAIL
CONTRACTOR } Ito I12.- S `f" C C 1 '
�sr Iib u,l,b..rc„,
I)c_K scc�f/ i, ZIP 4s'3-2_I FAX
WA STATE CONTRACIOR'S LICENSE* EXPIRATION DATE FEDERAL BUSINESS BUSESS LICENSE k is
l--J e t=i2 (7L_ 055 7)0- / /
NAME -.-PRIMARY PHONE
.. ;_rri e Y S Cc..--, c-_
APPLICANT MAILDN6 ADDRESS E MAIL
CITY STA'TE._. I ZIP FAX
NAME •
PRIMARY PHONE
PROJECT CONTACT
(The individual to receive and MAILING ADMIRES* MAIL
respond to all mrresponderuae
concerning this application) CITY STATE I ZIP -..
FAX
BAMS`-:
PROJECT FINANCING I
0 OWNER-FINANCED
When uahee is$5,000 or more MALLIN"Dusits,crrY,STATE,ZIP
CW 19.27.045) PHONE
(F
I certify under penalty of perjury that I am the property owner or authorized agent of the property iRnse- I c that to the best
of my knowledge,the information submitted in support of this perm it application is and correct.I�that I will comply with
all applicable City of Federal Way regulations pertaining to the work authorized by�p111 .tonce of ailiussitt. I understand that the
issuance of this permit does not remove the owner's responsibility for compliance 4 local, stat eor federal laws regulati
construction or environmental laws. ng
!further agree to hold harmless the City ofiederal Way as toecny violin/including costs,eccpenses an M°,,,
the and defense of such claim) which may be made by any person, including the undersigne lu"�� Abed furs�incurrede ty
but only where such alai es out of the reliance of the city, including its officers and employees, tinea ofthe
infors don supplied ty as a part of this application. icy
SIGNATURE: ..L DATE /+ 't
PRINT NAME: 1.S'h •-E_E S _ ,A,+;
Bona.'1o0--December 29.2015 .. 3 k:lliandotlts Permit Application