14-105982 OF 40616.4o, PERMI PLICATION
Federal Way
NOV 172014
110
PERMIT NUMBER 1 1- _ 5-Ct Er 0_ F-p
CITY j� F(�����
- - 'i'Aa9S ATE"N/ I 7 r `�
SITE ADDRESS
3/31 R n rte` (tau y 5, SUITE/UNIT#
PROJECT VALUATION 1// ZONING ASSESSOR'S TAX/PARCEL• /
$ 4974.00 b____ R" 7 `t - j if
TYPE OF PERMIT 0 BUILDING 0 PLUMBING 0 MECHANICAL 0 DEMOLITION 0 ENGINEERING FIRE PREVENTION
NAME OF PROJECT /7e/Z-141 G) 71,' ��ui `/ s- ter C/Z_
Q—2 df S //i Il (� 0, C f 5 71-454C4--71 014,4�z�
PROJECT DESCRIPTION '- l y2/
Detailed description of work to t/'7 Dai v h so or //Iv ec Feria S7/(ri
be included on this permit only r'f4O �/f /4 fz . 1 S ��( / . V
7
NAME /� ,� �Q PRIMARY PHONE
PROPERTY OWNER KII CV --ifiv^'L/'� '9-04 <ia1/?(( /
MAILING ADDRESS E-MAIL
CITY STATE ZIP
k.,, /0)41, pirp<4, -,-/%49. Ptcars-- 1.-;?,09
G-
CONTRACTOR 4715
slAp� $ 5.-...2a V P, '
nod
vise
47 ziPyTo7 2
WQ-$TATECOONTR R'S LICENSE 9 EXPIRATION DATE e_s--,70 -,7,.3
ERAL WAY BUSINESS LICENSE II
12t
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NAME/26 �r�� 0M�'p}ippg /��/
APPLICANT MAILING ADDRESS E-MAIL 3 (/I
CITY STATE ZIP FAX
PROJECT CONTACT NAME �� -4-7�-n[ r' 5-3 Jf_6 Gc. _r
(The individual to receive and MAILING ADDRESS 4E-MAIL
✓
respond to all correspondence
concerning this application) CITY STATE ZIP FAX
NAME
PROJECT FINANCING 0A! 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),w ch may be made by any person,including the undersigned,and filed against the city,
but only where suc, claim ,rises out of the chance of the city, including its officers and employees, upon the accuracy of the
information suppl . to t -city •• part of, is application.
SIGNATU. . �`�� '411111#111:11:c
LI/411W*!e f DATE if-q7-/t/
PRINT NAME:
Bulletin#100-January 1,2013 Page 1 of 3 k:\l-Iandouts\Pernut Application