12-102132 I
RECEIVED~ - 1 Z
PERMIT SF MF CO ME PL DE EN C)
Federal Way
cots f-2607*DEVELOPMENT 35-260CESY 15 20 pPLICATION
253-835-2607•FAX 253-835-2609
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CDS
SITE ADDRESS SUITE/UNIT#
,O�7 P ., �G �w�� � � k164 IAA qe6 C 3
PROJECT VALUATION ZONING ASSESSOR'S TAX/PARCEL#
$ ( ,S1C7001 iit . 5 0 0 - 0 6110 09
TYPE OF PERMIT 0 BUILDING 0 PLUMBING ❑ MECHANICAL
0 DEMOLITION 0 ENGINEERING FIRE PREVENTION
NAME OF PROJECT C
(Tenant Name/Homeowner Last Name) aVy1, . ' 0\A
S( I �I
PROJECT DESCRIPTION
Detailed description of work to
be included on this permit only
PROPERTY OWNER
NAME 1"1 Gj 1 c-L, I i A� t{�p.�I'i1 frpeG l 5 SO J J - °tct)
MAILING ADDS '`' V•"`
CITY I ( J U c.� V"✓`�ftT&
c1 705
NAME On
F21c /}/k1 5e ✓ kp ✓ //C PH
✓ r7!" -cF y I
MAILINGS� ADDRESS ,f.� r (/ E-MAIL
CONTRACTOR / p�4 (/ / / rr/11)
CITY TATE ZIP A 7 7--/4 6/1,03 FAX L,,.+„ r�"✓
WA RATE CO R'S LICENSE# EXEXPIRATION DATE FEDERAL WAY BUSINESSLICENSE#
r�� /,,,, / 3///� N� / A 7
NAME
I-7 n0k i'" 5tA5-ed PSG V (/ !(f
APPLICANT MADAYG ADD 7,/ d E
crrYG�i//�� STATE
�' 32 FAX�✓��� PS 22
PROJECT CONTACT NAME OP�(5 '��P/,. PHoNE C7
w f
(The individual to receive and. �) J
respond to all correspondence *N MAILING MAD/ '
concerning this application) CX 66 C /� 1�g� 4Cdt/i f % 5: .e,
CITY, `✓/ , ZIP c 32 FAX . J . !
ALTERNATE CONTACT
PHNE E-MAIL
x1/10(-IAA el e�,c� ot,t� 0?3'O3 S/��°lGzC; di,/ r--i6CP
PROJECT FINANCING NAME
pi OWNER-FINANCED
Required value of$5,000 or more
IRCW 19.27.095) MAILING ADDRESS.CITY.STATE.ZIP PHONE
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 b_ any person,including the undersigned,and filed against the city,
but only where such claim arises out of the reliance oft uding its officers and employees, upon the accuracy of the
information supplied to the city as a part of this j •
SIGNATURE: OP/1iDATE 5A14
PRINT NAME: /�� ��'/ (' f 7a
Bulletin#100-January 1,2011 Page 1 of 3 k:\Handouts\Permit Application