14-105814 &(_:d v 4- wt./ I t - - q
S
CrY OF PERMIT APPLIC MN
Federal Way
t ( a g t . 4- �b NOV p 6 2014
PERMIT NUMBER ` _ - TARGET DATE CITY OF FEDERAL WAY
— —
CDS
SITE ADDRESS SUITE/UNIT#
3i2-\C pI\Ct1`tc, Hwy �c�c ��� w (k)A, Ct?O 3
PROJECT VALUATION ZONING ASSESSOR'S TAX/PARCEL#
$ z, z b3 g 5 0 'k Z 0 Li _ � 0
TYPE OF PERMIT ❑ BUILDING 0 PLUMBING 0 MECHANICAL Q DEMOLITION 0 ENGINEERING R'FIRE PREVENTION
NAME OF PROJECT St P 4Z \ i \Z GALL
PROJECT DESCRIPTION U p Gv A O E K l iJ D'i W tt DR 2 6 C_L O N 1-\CZ�:. J p 12 t7` I o N
Detailed description of work to t IJ t 1 CANF 1.9 t4 U f-)\1 i U PAN!\1J e R C-Z LtZ t-0r AN;) lU L (r le ST
be included on this permit only 5 i A l)LW C Q 1 ,
NAME PRIMARY PHONE
PROPERTY OWNER 5 0 (Ai, Pi. M&- Pi-iv-LA, LL C
MAILING ADDRESS E-MAIL
2 ,S 6 L-( !v\ V i C W o 2
CITY STATE ZIP
DES t\i'lC I.3 S W i ctI t ca
NAME PHONE
Oi l NGoD k>JD DjCC SE�Utc.F , tib. ZO(L- 1ZE-oc04L
MAILING ADDRESS E-MAIL
CONTRACTOR L GC1 Z T RV �J •ti N t;� lQ12�t4C cC •CC
CITY STATE ZIP FAX
SF/kV-cue t C c 2Ci - z66-7-
WA
a iWA STATE CONTRACTOR'S LICENSE# EXPIRATION DATE FEDERAL WAY BUSINESS LICENSE#
RiacO0 0S7,6(-- c Z i i i iS iii H -105ori 1 ul -1;L-
NAME PRIMARY PHONE
SP\ME Av PN.Sou c
APPLICANT MAILING ADDRESS E-MAIL
South King Firey& Rescue STATE I ZIP FAX
nn���� �^�{ P PRIMARY PHONE
�ikelt�tl TACT t 5AM1= Ps l�
(The indl bt[tuai to ' t;- r e dlj}s 1 NG ADDRESS E-MAIL
res and to all cone
�i CITY STATE ZIP FAX
Dade
PROJE I 0 OWNER-FINANCED
Required value of$5,000 or more MAILING AI;DRESS,CITY,STATE,ZIP PHONE
(RCW 19.27.095)
I certify under penalty of perjury that I ant 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 ' -art o - application.
11
tSIGNATURE: hof '1 DATE 11
PRINT NAME: LS SC-\A = L�f
Bulletin#100-January 1,2013 Page 1 of 3 k:\Handouts\Permit Application