09-102811 OFREC ED - ( b
CITY
Fed�'�^ti/ "'
eral Way JUL 2 2aERMIT SF MF CO ME EL PL DE E1v��
COMMUNI YDEVELOPMENf SERVICES
41rRrIATCATION 253-835-2607•FAX 253-835-2609C�N �Cwww.cifyoj[ederalwau.com r
CDS
PROPERTY
SITE ADDRESS
3(? D/ eticNAAr7i,:,r7 Alie/twAy 50 .
SUITE/UNIT S ZONING ASSESSOR'S TAX/PARCEL N
2 S Z > G y - I Z 6
PROJECT
NAME Oor PROJECT Etl•1Ckx.w ie. 1d_ V' i f l o •C W>7�1(74-SrCati/4.06Cts
(Tenant or Homeowner Name) �
o BUILDING 0 PLUMBING 0 MECHANICAL ���� J/y] ) ,�/rXS
TYPE OF PERMIT ❑ DEMOLITION 0 ELECTRICAL 0 ENGINEERING J" FIRE PREVENTION
//VSTA//AT/oiJ ANSuc de/02 3,c) K/1//0A)
PROJECT DESCRIPTION $uP/92e5.5i0,0 5 j 5-r rr,
Detailed description of work to
be included on this permit only /°/Zo.r C% VAI u/IC 12e/65--
PEOPLE
PHONE
PROPERTY OWNER NAME 60- -��OWal}eO LtiC- 1( )PRIMARYIL
MAILING ADDRESS.CITY,STATE,ZIP E-MAIL
fa'eta
OWNER IS ALSO: 0 CONTRACTOR 0 APPLICANT 0 PROJECT CONTACT
NAME PRIMARY PHONE
,4,4A _-' ANo 5./rlt iy fuc (Z06 )5.‘i /7z /
�„� �,OR MAILING ADDRESS.CITY.STATE.ZIP FAX
/l•�NTRA
3a/3 3 A4 Our AG, 5 An";. 9Fie* (Zc6 )2C5/ -/7‘ ,
WA STATE CO R'S LICENSE I EXPIRATION DATE FEDERAL WAY BUSINESS LICENSE I
AAA .r5?��lO ✓JS / / 2G-oo-fo/633•oo-8L
NAME Q A /1 l PRIMARY PHONE
/�,4
APPLICANT / r A•V O 5A 7,�Ti t ) -
MAILING ADDRESS,CITY.STATE.ZIP FAX
)
PROJECT CONTACT NAME PRIMARY PHONE
(The individual to receive and ST/;. U/5 .-/-W c,7Ng i2. (ZS3) Zo 2- ?Z S�/
respond to all correspondence MAILING ADDRESS CITY.STATE.ZIP FAX
concerning this application) AHA 74/2e_ ( ) fA
ALTERNATE CONTACT NAME: PRIMARY PHONE E-MAIL GOrneA$j
( ) Tis TA/4144S6S e •.t/E i
PROJECT FINANCING NAME
0 OWNER-FINANCED
Required for projects with --
value of$5,000 or more MAILING ADDRESS.CITY.STATE, PRIMARY PHONE
(RCW 19.27.095)
)
I certf fy 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 lows 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 a part this , ,•Hendon.
SIGNA • _-," Ga DATE 7-2V-o,
PRINT NAME: / 5-7eV t; S%/1 o 7'HC/L
Bulletin#100-4/21/2009 Page 1 of 4 k:\Handouts\Pemlit Application