14-100193 RECEIVED
C€TV OF ' JAN.4 2(�14 PERMIT�PPLICATION
Federal Way JJ ff11' V
CITY OF FEDERAL WAY
/ ) CDS
PERMIT NUMBER / L{ / 0 O I 9 3- - r C- -----.____C- -----.____/ _ .! TARGET DATE
SITE ADDRESS SUITE/UNIT#
3`15y 5 qr" A\1E. S . 'rED£e A t_ \,J A`( Wil-
PROJECT VALUATION ZONING ASSESSOR'S TAX/PARCEL#
$ 2)-Z "i o 7 5 ° ti 5--- t - o o z o
TYPE OF PERMIT ❑ BUILDING ❑ PLUMBING ❑ MECHANICAL ❑ DEMOLITION ❑ ENGINEERING AFIRE PREVENTION
NAME OF PROJECT 5 P H *? Nhe.MA c----f
RlY/4�r A'i'l
/E!_
Re le c wt
PROJECT DESCRIPTION :Si,SP/^i ll /lees f'o 'r4.4T lAV r ove-0«f
Detailed description of work to
be included on this permit only
NAME r PRIMARY PHONE
,G
PROPERTY OWNER Frc iSc_QA t� �-
� ce� 1 C,co..3r 243•€-Iz4• y3V3
MAILING ADDRESS El-MAIL 14
CITY STATE ZIP
NAME PHONE
?ATP-tpT r-t C IS-1•317 - VLIz
MAILING ADDRESS E-MAIL
CONTRACTOR 2-1o`y '1 C ,4,VE-..." M1 ,8 p".{-r;,t•{,re .ce,,.)
CITY STATE ZIP FAX
-rq.cC.,#AAA- v`'k 98c-lzy 253-28'4 -3g8cD
WA STATE CONTRACTOR'S LICENSE# EXPIRATION DATE FEDERAL WAY BUSINESS LICENSE#
'Pa-rTe_IG PogatF to /off / ly Ig-al-fol qgg -oo -Bc.
NAME PRIMARY PHONE
APPLICANT MAILING ADDRESS E-MAIL
CITY STATE ZIP FAX
NAME PRIMARY PHONE
PROJECT CONTACT A4..4-TT- G e CEA-)
(The individual to receive and MAILING ADDRESS E-MAIL
respond to all correspondence SAME- A. S A-&O yr
concerning this application) CITY STATE ZIP FAX
NAME
PROJECT FINANCING 0 OWNER-FINANCED
Required value of$5,000 or more MAILING ADDRESS,CITY,STATE,ZIP PHONE
IRCW 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 itas a part of this application.
`/t3/,H
SIGNATURE: / j DATE
PRINT NAME: M hell— CZ F N(
Bulletin#100-January 1,2013 Page 1 of 3 k:AHandouts\Permit Application