17-101684 T
v.
RECEIVED
CITY OF PERMIT APPLICATION
Federal Way APR 13 2017 PERMIT CENTER+33325 8th Avenue South+Federal Way,WA 98003-6325
253-835-2607+FAX 253-835-2609+permitcenter@citvoffederalway.com
CITY OF FEDERAL WAY
COMMUNITY DEVELOPMENT•
c7"t
PERMIT NUMBER _ II _ J
TARGET DATE T
SITE ADDRESS SUITE/UNIT#
3 Ire.
PROJECT VAL TI ZONIN ASSESSOR'S TAX29 ' 1/PARCEL# 5 0 0 c 3
TYPE OF PERMIT
,❑ B�UILDINGl❑ PLUMBING 0 MECHANICAL ❑014
DEMOLITION 0 ENGINEERING IRE PREVENTION
NAME OF PROJECT ��6/`I'�I DUs 1 �t
PROJECT DESCRIPTION 411
Detailed description of work to 5C4, 1 / 'L/ /941IO1/
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be included on this permit only n,fit)
4
Mk) r 14&r( ' t. f 2 3 ..�2
PROPERTY OWNER i •DRESS
OV. lAV( L� E-MAIL
C / `/h,'Teel ZIP
NAM$ 'I, ♦ 4- lavi 1
W' 57 qO O - V
MAILING'INADDRESS.7 1(„- c .. e htll; � ,w.09�-
CONTRACTOR .1"]]] /7� `�/,�[ 4/� W�
CIIF/�� $T¢T$, ZIPIy,•���V Wig VU lY
W aqT {„ Ojt'S I i ; # W fl`\l ��[iRATIOONNDADATE FEDERAL WAY BUSINESS LICENSE#
I�� O i 6 j cel /o 703
NAri elDl S '' , 4- i‘cA.Ak 02667 Pm 7G -&J-
MAILING AD
APPLICANT ( � � 1 1/4 '( C eX- �/�Vt�a�}��W ��1'/4
CI N
PROJECT CONTACT /�,, i e. It!! : e.��IV/i1,4f9IA� ) *� P� �PH.„ .� 1
(The individual to receive and ?AMU�G AD s Q,�,rty� �/ /��/respond to all correspondence l'v r (;V 1 I'�"^ JJwL ( "lI1 iI 1-9.oh
concerning this application) CITY SVO4 2IP
b32..
• -g .C9g).1
NAME
PROJECT FINANCING -0 -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 harmles he City of Federal Way as to any claim(including costs,expenses,and attorneys'fees incurred in
the investigation and defense of ch claim);which may be made by any person,including the undersigned,and 'led against the city,
but only where such cl' m • :es •ut of the reliance of the city, including its officers and employees, upo he accuracy of the
information supplied t. h -;*,y/part of"is application.
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SIGNATURE: _ rA44jDATE 1 / 9-
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PRINT NAME: ..: A/V4
Bulletin#100—January 29,2016 Page 1 of 2 k:\Handouts\Permit Application
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