14-106253 11111616 eclIVED
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CITY OF PERMIT IRPPLICATION
Federal Way DEC 0 8 2014 2:-�
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CITY OF FEDERAL WAY
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LCpi
PERMIT NUMBER / _ � TARGET DATE
SITE ADDRESS �L SUITE/UNIT#
3i i / y S -
PROJECT VALUATION ZONING ASSESSOR'S TAX/PARCEL#
TYPE OF PERMIT ❑BUILDING 0 PLUMBING 0 MECHANICAL 0 DEMOLITION 0 ENGINEERINGVFIRE PREVENTION
NAME OF PROJECT Cr F F/C <_ 444 1!
A.e p L/a e (v-Jo gv _1� p�. L C iO a .-
A.0, 11 4
PROJECT DESCRIPTION
Detailed description of work to 6u j Am 03 1l 10 N L. A 44 L i /< 444 fir ` Z. 027
be included on this permit only
1�DA� ss1 til
NAME PRIMARY PHONE
PROPERTY OWNER
MAILING ADDRESS E-MAIL
CITY STATE ZIP
NAME PHONE
51NYL SC, err 1 ti 25 -76 7 7 02
MAILING ADD S ,y!^ E-MAIL .S'��INC/(,B,4jR.
CONTRACTOR 2 70 f) I c.f�A?O r R L J/ Z� N vi.t/i to, PiC� I�1�SUf
CITY/3
ITYSTAA. FAX ctLc
5
WA STATE CONTRACTOR'S LICENSE# EXPIRATION DAT FEDERAL WAY BUSINESS LICENSE#
E PRIMARY PHONE
-f� 41941 ,c1 Q1� 'o'V LjL.c 757 77l 7-5 -
APPLICANT MAILING ADDRESS
2200 Rialetwa2 f t L zv 'z- i-Ies QD , P oso gOS,d yAie,lO.
TY
lraLQ10/ CTAlk
•`2//6 - e�� ��
NAME PRIMARY PHONE
PROJECT CONTACT ;53- 3°j r 1/3 7-I
T-he-i-nd-i'idual-to-rete-ive-ar6 -- MAILING ADDRESS E-MAIL
respond to all correspondence • '-I
concerning this application) CITYTA - p FAX x.,53 �- 43`f gS
NAME
PROJECT FINANCING D 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 any person,including the undersigned, and filed against the city,
but only where such claim arises out of the reliant- of the city, including its officers and employees, upon the accuracy of the
•infer^alio..supplie to thee
..i+t,asap„, of+a; Cpl; t
SIGNATURE' t' / DATE 12' b-2-0 I 1
PRINT NAME: rS -111 e6 12 L -AAA 2,6s'oA7
Bulletin#100-January 1,2013 Page 1 of 3 k:\Handouts\Permit Application