17-100767 . r,f
i► IVES PERMIPAPPLICA'TION
CITY OF
PERMIT CENTER+33325 8 Avenue South + Federal Way,WA 98003-6325
Federal Way FEB 2917 253 835 2607 + FAX 253 835 2609 +peuiuitcenter@cityoffederalway.com
CITYOF FEDERAL NAY
PERMIT NUMBER / 7 -. /
/ - �E io ------ --,._.._./
TARGET DATE
SITE ADr, ESS SUITE/UNIT#
41
Is r3
(C� ``- ..vo •
__:: ,1 1 `j4 5:r
PROo CT VALUATION ZONING ASSE SOR'S TAX/PARCEL#
TYPE OF PERMIT ❑ BUILDING ❑ PLUMBING ❑ MECHANICAL ❑ DEMOLITION ❑ ENGINEERING FIRE PREVENTION
NAME OF PROJECT4 EC
PROJECT DESCRIPTION I- i 21 -3 , / /ex) J C 7
Detailed description of work to
be included on this permit only
NAME ,,Q / /' PRIMARY PHONE
PROPERTY OWNER j /`�} G C-Rg, /T_4Y
MAILING ADDR 1W L ^ f\K. ` E-MAIL
CITY (,STATE ZIP
NAME PHONE
CAIDDRESS E-MAIL
CONTRACTOR
STATE ZIP FAX
dd b
CONTRACTOR'S LICENSE# P _�� �� EXPIRATION DATE FEDERAL WAY BUSINESS LICENSE#
/---77
/rg4 z PRIMARY PHONE
MAILING ADDRESS _ E-MAIL
APPLICANT Q 1.). 0 /9k0- 541
(- �� ����� �-
CITY ST E ZIP FAX ""c- -Cil---
j�
NAME Li
I,, PRIMARY PHONE
PROJECT CONTACT �J
I -C� MA -J,p0 ei _
(The individual to receive and MAILING ADDRESS E-MAIL
respond to all correspondence _
Concerning this application) CITYSTATE ZIP FAX
NAME
PROJECT FINANCING7t 0 OWNER-FINANCED
When value is$5,000 or more MAILING ADDRESS,CITY,STAT ,Z PHONE
(RCW 19.27.095)
I certify underpenalty of perjury that I am the property owner or authorized agent of theproperty owner. I certify that to the best
of my knowledge, the information submittedin 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 cla ,-;which may be made by any person,including the undersigned, and filed against the city,
but only where such claim arises o of reliance of the city, including its officers and employees, upon the accuracy of the
information supplied to the city •: a p. •,"this •ppllication.
SIGNATURE: e ilii` �'C i- 7/ DATE ' / -----/.
PRINT N• E• , • J `/� .--AI
Bulletin#100-January 29,2016 Page 1 of 2 k:AHandouts\Permit Application