13-101694 P'"
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47731VE. D PERMIT APP � ;:19N
Federal WayI :tl170(44)
PERMIT NUMBER ! J — ( OI //f 9 1_ coAPR���GGC/// TARGET DATE CITY OF FWAY
SITE ADDRESS SUITE/3i L Rc +'IC IAt5t , cbPROJECT VALUATION ZONING ASSESSOR'S TAX/PARCEL#$ goo o � a 1 o '.( - q ( 6
TYPE OF PERMIT ❑BUILDING ❑ PLUMBING ❑ MECHANICAL ❑DEMOLITION ❑ ENGINEERING, NTION
NAME OF PROJECT auk' tons 1 eg.OL s A
%5 C
PROJECT DESCRIPTION -�"�l �C��0
Detailed description of work to
be included on this permit only
NAME PRIMARY PHONE
PROPERTY OWNER Grtck 90 ec-(e.s
MADDRESS
(v)_\ re E-MAIL-M"Tux (. .0
CIT T� ZIP
�,Mc - d (�� -- R ?
NAME �I/ , nC D £vK. '-` C •906-30b- ASPHON
MAILIB ADDDDDDRREES1���5�,,,[[[f E-MAIL�
CONTRACTOR (X 2V t�C)4 4 Mkt kt tAGLA® I(A G64,coM
CITY STATE ZIP FAX J
WA
WA S\Z./CONTRACTOR'S LIC S II EXPIRATION DAT FEDERAL WAY BUSINESS LICENS
NAME
(,5 W A l l4 /C'�(
PRIMARY PHONE
APPLICANT MAILING ADDRESS T E-MAIL
CITY STATE ZIP FAX
, PRIMARY
PROJECT CONTACT NAME ,V 0.C 1°` t I 1 MO PHONE32t/ 496(/
(The individual to receive and MAILING REsrs� 1- E-MAIL /V�U'
respond to all correspondence c]D /nkrp rf Y`f t r 5 - yrj11(/ o Nlsi'G�4.41i"�
concerning this application) CITY 1 T TE� ZIP 64 F A `/�'
NAME `.ku• e _. Y q5 I Po 19- • fiOl 1
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 maite by arty person,including the undersigned,and filed against the city,
but only where such claim arises out of the reliance of the ity, including its officers and employees, upon the accuracy of the
information supplied to the city ' -a part of this application.
SIGNATURE: -7 k
DA '4 a
PRINT NAME: ) /,C- /
Bulletin#100—January 1,20 3 Page 1 of 3 k:\Handouts\Permit Application