13-105641 • 4
CITY OF PERMIT APPLICATION
Federal Way MEWED
PERMIT NUMBER 1 _ I 0 _.J 6 4 ( _ FP' DEC 19 2013
TARGET DATE
-
'� � CITY OF FEDERAL WAY
SITE ADDRESS ��...- ,l /�/� /�,,� SUITE/UNIT f2DS
f�
PROJECT VALUATION ZONING ASSESSOR'S TAX/PARCEL#
$ Ci2g00 2 $ 2 10 4 - a D raG
TYPE OF PERMIT ❑ BUILDING ❑ PLUMBING ❑ MECHANICAL 0 DEMOLITION ❑ ENGINEERING IRE PREVENTION
NAME OF PROJECT \ (i l� .kve s - ►T mbec hc.w K _
1 l `
PROJECT DESCRIPTION CC>>f'C k- %fi e.. rAP\fI S (t'r cI. R tcce 1�1�L mil., rz re_
Detailed description of work to GIN-Al COncca tzerv2 (Q t� e tt.41 t to 605 Ct✓� l`-t1 ,e S
be included on this permit only 1
NAME p 0 �� PRIMARY PHONE
PROPERTY OWNER i‘CAW. I G.c VS 1 �C
MAILINpDDR ^643�� E-MAIL
CITY ��`` 1 $
STATE ZIP riss_
NAME \1/4651.11.n � A' 1-r\C • ' PHONE. V -32$`6
CONTRACTOR MAILING OS I\U )O -L Vie sT�` mattE-MAIiF ' otzslN 40L
CITY S�It Y �1 Z°cisl3�( ,e-322- Z14!
WA ST TE ,CONTRACTOR'S�`� I► .-.. �� i oV EXPIRATION DATEFEDERAL WAY BUSINESS LICENSE#
143siic
NAME PRIMARY PHONE
APPLICANT MAILING ADDRESS E-MAIL
CITY STATE ZIP FAX/ �j
PROJECT CONTACT NAME s t(�( f•. 4CTFA
\WCON G.OtO �+�-N - JZ€6
(The individual to receive and MAILING p(DD�RESs ,\ \• yE-MMAIL I
respond to all correspondence L.03b �tC' e YC �(/ S' r�911C.tliti61 �(j5Mli4s '4MZfdt
concerning this application) CITY . 1 S AT//E�� ZIP/'+ '.`( FAX
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 application.> // �/%
SIGNATURE: ;j�,":14/i -/ .7.-- L DATE l2l l / W l3
PRINT NAME: ,v c k Alt 1 C-1 t j-Ci
Bulletin#100-January 1,2013 Page 1 of 3 k:\Handouts\Permit Application