10-103759 , 0 - l0 375`9
CITY OF HERMIT sollr,EZEIV Sake
Federal Way
COMMUNITY DEVELOPMENT SERVICES APPLICATION SEP' 01 20.0
253-835-2607•FAX 253-835-2609
www.cituollederalwau.corn ' r.taEv1/i A _ I n )j rn q //0
(�/FI �7`� Ll/ CI/// OF FEDERAL WAY
SITE ADDRESS CEUSTY /UNIT#
PROJECT `VALUATION C C `ZONING W ' ASSESSOR'S TAX/PARCEL#
$ 0 8 2_ / 0 4- _ 67 0 7 gt-
TYPE OF PERMIT 0 BUILDING 0 PLUMBING 0 MECHANICAL
0 DEMOLITION 0 ENGINEERING X`FIRE PREVENTION
NAME OF PROJECT
(Tenant Name/Homeowner Last Name) ' R B IOC k
PROJECT DESCRIPTION -,',-�-�kk6.-�`... 0f q- 5''''�'t''kc•' d c �-r<<r-i c J I- �afv`p-rr,he
Detailed description of work to 1 - 6+,-'l t' "tc.. E'' ,'51-t h c, F A 5 154-e+
be included on this permit only
NAME PRIMARY PHONE
PROPERTY OWNER
(
MAILING ADDRESS E-MAIL
CITY STATE ZIP
- PHONE _.
NAME / . let c
1 !` rrL -p`LCI -Cr'rC
c/NTRACTOR 7 3`( .jig 3,2-1t/5L_ ✓'(/ih /0.2 (:l/._L.r1,E.)/o,FPh=ri-yC.Ate L
•
CITY I STATE ZIP _ FAX
t, /7)e .l"le...tL
W 1,24. `�t ic/ -33�t -3?i.l
F�XPIRATION DATE FEDERAL WAY BUSINESS LICENSE#
t'STATE CONTRACTOR'S LICENSE#ALL:! Nl'-`1'7,4 137 ' / E= /...ki/ )c -b-si-/03J -ex' -84
NAME PHONE
k /_'. ie-t )1,/,' c d04-•ri 30 -Woo
APPLICANT MAILING ADDRESS E-MAIL
731 S'E -3 ... '5i- 5ir•i .) dti---/vAk.e.le,/,t ,st-Lf
CITY, �'•�' STATE ZIP /�[�/� FAX
/" Ie/eel` .�S4nit �'�_ 9'1(/ltd ai - 23..—"37t't
PROJECT CONTACT / �
(The individual to receive and NA1 ''44--'C>/Jv'3 ke PH —r)3�. Z/�
respond to all correspondence �}J�I G ADDRESS EMAIL j?/ /
concerning this application) 3 5G 3 ci......�' 19X ekc-4r._ •,Ie,t
C STATE FAX
ZIP
.'s 4,1 J A.,./.4... ‘l e ( qty, -3.2-3 7?.Z
AL RNATE CONTACT NAME: PHONE E-MAIL
PROJECT FINANCING NAME ❑
OWNER-FINANCED
Required value of$5,000 or more
(RCW 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 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 city as a part of this application.
SIGNATURE: 87-12:494.01 ; DATE `s 'f C�
4,4- A �. 'Act
r
PRINT NAME: J 1"
Bulletin#100-April 14,2010 Page 1 of 3 k:AHandouts\Permit Application