16-103971 •CEIVED
CITY OF PERMITPL
Federal Way
AUG 1 5 2016 ICATION
CITY OF FEDERAL WAY
el CDS A y�
_ / _ /
— — TARGET DATE F
PERMIT NUMBER 1
SITE ADDRESS SUITE/UNIT#
2.7 5 IS Pjf t PIC, NMww 5 .
PROJECT VALUATION ZONING ASSESSOR'S TAX/PARCEL#
$ S.000 .oa 3 3 ' Z� 0 Li _ -i i 2-
TYPE OF PERMIT 0 BUILDING 0 PLUMBING ❑ MECHANICAL 0 DEMOLITION 0 ENGINEERING 4FIRE PREVENTION
NAME OF PROJECT 1 INA`Do 0)
'
PROJECT DESCRIPTION RDOK w caewl1(Au 1 )) H 4- Nu/-
Detailed description of work to 5utfatscoss rim—m- -r0I pg-E v'w%5) Roth)
be included on this permit only
NAME PRIMARY PHONE
PROPERTY OWNER
MAILING ADDRESS E-MAIL
•
CITY STATE ZIP
NAME 5HttaNiStr4 '"1 ift. Pvl 6 b ir:— P2! }6 73C 36v"
MAILIN RESS ems EL
CONTRACTOR + 10 O J i r Dat'tJ .Dome-IJ a sol '
CITY �� 1 ,1 STA_ TF ZIP,46106
FC2 I5) 217 1531
WA STATE CONTRACTOR'S LICENSF�#ik- l/V•I EXPIRATIONN DATE FEDERAL WAY BUSINESS LICENSE#
_ - _.
91.14D -��Q �1 55DD1N�1 '� 15 1� Pt; y
NAME _ `ke6UN PULE f rfi `� P O` "PHONE ��/ .. _
APPLICANT MAILING ADDRESS 1 6
_ '7'111 tn�� J JR, bCilE d5 .wa-
CITY 1 ,t r`n/1 X31 ST _ ZIP n -,C62)7,17-63)7 7 f r(';
NAME V (A) M��,� 1 F/Vl P YY PHONE? q
PROJECT CONTACT C V"a-lG"vl V N 293 '709-
(The individual to receive and MAILING AD�D/RE S ,f y T y�� E-MAIL
respand to all correspondence (q lkiNS1 DAL •" CYC.IIrtSSY)@SCS ci. •e(owl
concerning this application) CITYUU"i� STA ZIP �,91 AX
31277.153'0
.._-.. NAME
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 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 t he city as a part of this application.
SIGNATURE: DATE >(V fi b
PRINT NPME: 't /f V& CA4'
V
Bulletin#100-January 1,2013 Page 1 of 3 k•\Nandr:nt,\Permit Annliratin.,