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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