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12-104473 / A - ± 0 (-1 (-/2 • PERMIT • MF CO ME PL DE EN P Federal Way COMMUNITY DEVELOPMENT SERVICES APPLICATION RECEIVED 253-835-2607•FAX 253-835-2609 WWII!.cif uolftrierahrate.corn OCT 01 2012 SITE ADDRESS SUITE/UNIT# 312 �✓i2G 1,'w CITY OF FEDERAL WAY / CDS PROJECT VALUATION''J ZONING ASSESSOR'S TAX/PARCEL# $ /be)C" ( . x— .1 0 Y - 9 L / TYPE OF PERMIT ❑ BUILDING 0 PLUMBING 0 MECHANICAL ❑ DEMOLITION 0 ENGINEERING /FIRE PREVENTION NAME OF PROJECT (Tenant Name/Homeowner Last Name) /) May / / PROJECT DESCRIPTION at 3 f*, 0 � U���`z`'�/'`7 sys�� - 4l3C/ Detailed description of work to be included on this permit only NAMEPRIMARY PHONE PROPERTY OWNER MA UO e , MAILING ADDRESS E-MAIL J CITY STATE ZIP NAME PHONE r-,,aI> K I., 1).-.4C--_ 2-40e.: 229'3-2.`-1 MAILINGADDRESSE-MAIL / CONTRACTOR -7 t/v' / 5 (e25S CITYSTATE ZIP FAX k -. 0- WV 9 yz WA STIE CONTRACTOR'S LICENSE# EXPIRATION DATE FEDERAL WAY BUSINESS LICENSE# �Y4z _Ff. I, SNS) SC'CC_ _ 02. / 2/_2vlL NAME PHONE b 1-'Y/?1 7 1,4-- 2a/-�-l 5-2 4/- APPLICANT MAILING ADDRESS E-MAIL -j ff-------- 3/o (l )� nie-sOti ;skI * 46trei; .•- CITY STATE ZIP FAX kt'")"1--- ✓/r Id',e7K?— PROJECT CONTACT NAME PHONE (The individual to receive and respond to all correspondence MAILING ADDRESS E-MAIL concerning this application) CITY STATE ZIP FAX ALTERNATE CONTACT NAME: PHONE E-MAIL PROJECT FINANCING NAME El OWNER-FINANCED Required value of$5,000 or more (RCW 19.27.095) MAILING ADDRESS,CITY,STATE,ZIP PHONE 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 arty 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 part of this application. SIGNATURE: A DATE I©- PRINT NAME: / en.it Bulletin#100—January 1,2011 Page 1 of 3 k:\Handouts\Permit Application