17-101926 4‘.
PERMIT APPLICATION
CITY OF .
Federal Way PERMIT CENTER+33325 8th Avenue South+Federal Way,WA 98003-6325
253-835-2607 +FAX 253-835-2609+permitce g> ettivl n) Im
- _F-,,,0„,,
I I _ APR 2 7 2017
PERMIT NUMBER I
TARGET DATE lv1CIT�l�.OW
SITE ADDRESS �,OMMkraa��unIVIEV OPMEN
Z,003-0 9'o411 FL 514% f .1ey4.I it > kA ?8o23
PROJECT VALUATION ZONING ASSESSOR'S TAX/PARCEL#
$ 0 1 z ; o 3 - r-f
TYPE OF PERMIT ❑ BUILDING ❑ PLUMBING ❑ MECHANICAL ❑ DEMOLITION 0 ENGINEERING Ig FIRE PREVENTION
NAME OF PROJECT Sh Cr 4 / A WI -1 �f P
h�
PROJECT DESCRIPTION I`FPA 13 D gge i f\V+&' - Soil
' it amt jy
Detailed description of work to -I-A, crtAt1e y I-iftic , 14
be included on this permit only
NAME PRIMARY PHONE
PROPERTY OWNER
Se- '�t)-111 a }\i E-MAIL
3 o o/
CITY / STATE ZIP
J-- ei "- 4� 9 iA 60 02-3
NAME i- ... PHONE
Co/1,0,191 k .FI t (290 y31,- i s64
MAILING ADDRESS (Ti E-MAIL
CONTRACTOR IN r'•A l !eq.
CITY l STATE ZIP FAX
5-en-r lit/ PA 9,610?)
WA STATE CONTRACTOR'S LICENSE# EXPIRATION DATE FEDERAL WAX BUSINESS LICENSE#
0Li" i -c2 �C ,' / z 3 /0 20-0y- oottc7-0o-8L-
NAME PRIMARY PHONE
/i L, i-I' 0,70 - 232-- Sco
APPLICANT MAILIING ADDRESS y/ E-MAIL /) �//j /
CI'1I/ 5 , 1 1 A A itif 7 STATE ZIP FAV J/(, IJ'( VZ
ii,--i I e. /
Y
S-aksrfie I,Va qg /0 5
NAME PRIMARY PHONE
PROJECT CONTACT
(The individual to receive and MAILING ADDRESS 5 avvit, 0rA mi i otv fi E-MAIL
respond to all correspondence ( �
concerning this application) CITY ,--------''------ STATE ZIP FAX
NAME ((,,
PROJECT FINANCING kVA ❑ OWNER-FINANCED
When value is$5,000 or more MAILING ADDRESS,CITY,STATE,ZIP )� PHONE
(RCW 19.27 095) N/
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: _ '..-%:-'7 DATE tlj
/2 7/�
PRINT NAME: b C�.-4 2-i
Bulletin#100-January 29,2016 Page 1 of 2 k:AHandouts\Permit Application