13-101697 • 0
are oFe ApplovED PERMIT APPLICATION
Federal Way RECEIVED
PERMIT NUMBER I ,/ _ I `' 1 6, C1 E?ET1
0 0 APR 18 2013
_ TARGET DATE CITY OF FEDERAL WAY
CDS
SITE ADDRESS SUITE/ NIT#
n
- l ,
e9 -7 9 .c«Cci (4\10.y . t31 q5 F
PROJECT VALTION ZONING ASSESSOR'S TAX/PARCEL#
$ cf06 Qts ai_ o '4 - Qt1_ 61,
TYPE OF PERMIT 0 BUILDING 0 PLUMBING 0 MECHANICAL 0 DEMOLITION 0 ENGINEERING RE PREVENTION
NAME OF PROJECT ,.\1110n5 11 ll1cP6
PROJECT DESCRIPTION
—,..4\5 l 1 AES c A c, i2nSurn C'
Detailed description of work to
be included on this permit only
NAME 4( PRIMARY PHONE
PROPERTY OWNER ?(OF
liA I e g
MAII.�¢QDORP�S//�y1'' 6� ^17 LCI r<\- TE ZI/P �/cx r..NE4c � �
NAME \ lAin A lar I� P(/� C/V 5
MAILING AD RESS A9'oi4
CONTRACTOR O( `� t�y i ;711,1Glh6v"/"'`" , /C(A CBlel
CITY �^C` lk l� �r E ZIP Cj 6 ( FAX
, rV 14 1
WA
\ JAaSTE Cg's 1) /ObN DAT jEDERAL WAY/ fl -DO 1n169WA 66 gE(3L
NAME 1 -\U'1‘4 1• tn Wt4IAA464(456 A Ifs` PRIMARY V PHONE
39 V 30e6
APPLICANT MAILING ADORES E MAI
a/o 31 '�91 �<< � ' S r`/�� {�, 1�y►�AWt.iif� asigint(ci tot\
CITY ��'�'1.J�1 1 Y V P l ifb 1 V"V S OD •rid I
NAME PRI l�PH�OtJNE�
"'saPROJECT CONTACT (\ - /- A cTlCnfL;ln
The individual to receive and MAILING ADDRESS ,,q /� L \, E-
respond to all correspondence 7� Y-1 IC�DI C `i"r^J`� 1tni�/l�� l�j il�{ n
concerning this application) CITY^ \ n srnTAE ZIP/tit 1 3� / FA 0(p r`309- 11
NAME ,i W^� 1. I
PROJECT FINANCING 0 OWNER-FINANCED
Required value of$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 of such claim),which may be made by arty 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.
SIGNATUREi ' � DATE </ %7 i
mor
NI
PRINT NAME: ��A _ v.-' ( ..,., , ,r
Bulletin#100—January 1,2013 Page 1 of 3 k:\Handouts\Permit Application