16-102064 ReC�ivEr )%/-.34. . •oo • O 0 a,
M �3 • PERMOT APPLICATION
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CITY OF 2Federal lillay 9 2016
APR PERMIT CENTER+33325 8th Avenue South+Federal Way,WA 98003-6325
OF � y253-835-2607 + FAX 253-835-2609 +permitcenter(dcityoffederalway,com
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CIT'Y� CDS
PERMIT NUMBER w — i 0 �" 0 y — r ..?
iji A
TARGET DATE
SITE ADDRESS SUITE/UNIT#
C—SS \C_- \-\-t 7 `) -
PROJECT VALUATION ZONING ASSESSOR'S TAX/PARCEL#
TYPE OF PERMIT ❑ BUILDING ❑ PLUMBING D MECHANICAL ❑ DEMOLITION ❑ ENGINEERING FIRE PREVENTION
NAME OF PROJECT
C_ -(1._ -\c'y`>
PROJECT DESCRIPTION 2 LNC C---_X 1�-T\AJ(_., C 10. e7-t vrc_ F I t2c= I L(s(l i)(N.v(-(
Detailed description of work to L7\-i---0c- ) v`LL=`' (-:- I(Z_6- L,t 12c' /ALd>IC v- '7 A&YL C
be included on this permit only
NAME PRIMARY PHONE
PROPERTY OWNER /= IL1 L`l7 L'a-Psc
MAILING ADDRESS 7:11::
7�r E-MAIL
j5 — A-Vi- ..At/-- �Y
CITY_ STATE ZIP
77( e•14,e-- `2/T 959"
NAME PHONE
'X.7-Z----"6 liV/-5-7 /ASC. 5'3.3-/2 cy ic
MAILING ADDRESS E-MAIL
r7
CONTRACTOR 72(.s (--- 0A/pi-66.- '�r', A/ fvi 7Z----
e.TellSTATE / ZIP FAX
' i/4-C/7:-/(, i(/1/4- ?U6g-1 i
WA STATE CONTRACTOR'S LICENSE# EXPIRATION DATE FEDERAL WAY BUSINESS LICENSE#
rig( <, v,s-s-i_ 1 3/ / /6, 1q _47 - ( /,-/-5,
Y NAME PRIMARY PHONE
APPLICANT MAILING ADDRESS E-MAIL
CITY STATE ZIP FAX
NAME PRIMARY PHONE
PROJECT CONTACT /kf'A7`" CA A-C,<,7r-a-A/ / f- `/S""/ - S )�
(The individual to receive and MAILING ADDRESS E-MAIL
respond to all correspondence S/k" Z.--
concerning this application) CITY STATE ZIP FAX
NAME
PROJECT FINANCING ❑ OWNER-FINANCED
When value is$5,000 or more MAILING ADDRESS,CITY,STATE,ZIP PHONE
(RCW i 9.27.095)
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 • t as a part of this application.
Z' ; �
SIGNATURE: - DATE
PRINT NAME: MAIr 514 A/
Bulletin#100-January 29,2016 Page I of 2 k:',Handouts\Permit Application