17-101046 RECEIVED PERMIT APPLICATION
CITY OF
Federal Way MAR MAR 06 2017 PERMIT CENTER+33325 8th Avenue South+Federal Way,WA 98003-6325
253-835-2607+FAX 253-835-2609+permitcenteI13citvoffederalway.com
CITY OF FEDERAL WAY
CDS
PERMIT NUMBER 7 - / 0 I C F
iJ P TARGET DATE )// ti
SITE ADDRESS SUITE/UNIT#
33 �JJ0 `, l L I-ezleVu.k lil..4:i- tic
GNt
PROJECT VALUATION ZONI r� ASSESSOR'S TAX/PARCEL# l v✓
_7 9 7 e3 c22u - 0 C C
TYPE OF PERMIT ❑ BUILDING ❑ PLUMBING ❑ MECHANICAL ❑ DEMOLITION ❑ ENGINEERING,'FIRE PREVENTION
NAME OF PROJECT
w
Gov
,
PROJECT DESCRIPTIONv
Detailed description of work to
be included on this permit only
NAME PRIMARY PHONE
'IV-AOCa1nce
PROPERTY OWNER MAILING ADDRESS E-MAIL
CITY STATE ZIP
NAME PHONE
nkP f= {c'( s �kr s-y 0253 74 7 f
MAILING ADDRESS E-MAIL
CONTRACTOR ICj(s �C; IZ�L SGIG-. . (.,,code CO.60, .
CITY STATE ZIP FAX
w. 9 go 3=2- 8S3 7q 6 ??(# 7
WA STATE CONTRACTOR'S LICENSE# EXPIRATION DATE FEDERAL WAY BUSINESS LICENSE#
T /CO Z� S 09c-,00i i 1�1-wf��Ic�sS67-c;�c 3�
N E PRIMARY PHONE
TV CO �‘:.7\eC yvkec �V:- ( ;25-3 7q4
APPLICANT MAILINb ADDRESS by E-MAIL
1�]6.1.2S /due LOCC) �e � C�3 cot..
CITY STATE ZIP y FAX
NAMEPRIMARY PHONE
C�.
PROJECT CONTACT l v ev. b e i t I L..,e,w��� iy Ali V. tUr c 3 `,C�( 7 3
(The individual to receive and MAILING AD RESS y_� E-MAIL
respond to all correspondence 1Ci(p r& baAve- ` �\ Cvr`� '�` J I C o
concerning this application) CITY STATEJ� ZIP FAX
e�-� (JIy C'0c&).. ., 5'3 - x)61
NAME
PROJECT FINANCING OWNER-FINANCED
When value is$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 • -uch claim), which may be made by any person, including the undersigned, and filed against the city,
but only where such clai a/hr.' • of the reliance of the city, including its officers and employees, upon the accuracy of the
information supplied/t. a c' t of this application.
SIGNATURE: `� DATE /Sot 7
/
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Bulletin#100-January 29,2016 Page 1 of 2 k:\Handouts\Permit Application