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15-102591
CITY OF • PERMIISAPPLICATION Federal Way RECEIVED MAY 2 9 2015 _ PERMIT NUMBER 0 TARGET DATE CITY OF FEDERAL WAY CDS SITE ADDRESS SUITE/UNIT# C27aIO ?AGlyle �iit)/ g PROJECT VALUATION ZONING ASSESSOR'S TAX/PARCEL# $ ,Coo. 2 o r g D _ TYPE OF PERMIT ❑ BUILDING ❑ PLUMBING ❑ MECHANICAL ❑ DEMOLITION ❑ ENGINEERING Nr FIRE PREVENTION NAME OF PROJECT C (/1 E bg-i A p��14�1�&rr EL* --It'C PROJECT DESCRIPTION k� 1,01-4-y £ FOC Detailed description of work to be included on this permit only NAME 4.142T-pies PRIMARY PHONE PROPERTY OWNER CaEs-rYalFgJ ' sT A? 41 1EA'1 MAILING ADDRESS E-MAIL I7 71C -1)0.r 7c nt/eS MeetoelRL Oe CITY 8`,n, l� STAT Z`9 "o' �F-1 y �1 , NAME �7 PHONE Ti-TQ-t o T —1ev-re C fi) MAILING ADDRESS E-MAIL CONTRACTOR 27076P 701 AVE CITY STATE ZIP FAX fica4Al- w R if 4a y WA STATE CONTRACTOR'S LICENSE# EXPIRATION DATE FEDERAL WAY BUSINESS LICENSE# Pr IF0n99cr fO /©S //- /4- II llma -oo-�L NAME PRIMARY PHONE rel ''�p-10 r Fg-a-rtc-rioio APPLICANT MAILING ADDRESS E-MAIL CITY STATE ZIP FAX NAME P MARY PHONE PROJECT CONTACT i bsi$W TA-K►-li XOI C(/ 53) 028*-6111-3 (The individual to receive and MAILING ADDRESSA l E-MAIL respond to all correspondence .2101 70 14-✓�Z g 1.43friAN 16e it=tC'"1-I concerning this application) CITY STATE ZIP FAX /QCdvti.ct; cJ� r 1 Ll NAME PROJECT FINANCING 0 OWNER-FINANCED 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 a,•lication. SIGNATURE: DATE ch / - PRINT NAME: QOf1A-l7d Bulletin#100—January 1,2013 Page 1 of 3 k:\Handouts\Permit Application