16-101439illir AL REMED
MAR 216
A. IMP
2U `� PERMITeiPPLICATION
CITY OF ' -
Federal WAYWay PERMIT CENTER+33325 8th Avenue South+Federal Way,WA 98003-6325
C OF FEDERAL 253-835-2607+FAX 253-835-2609+permitcenterAcitvoffederalway.com
// CDS
PERMIT NUMBER 6 _ C j / 3 / _ ��
/ TARGET DATE lk__(0,,_,
SITE ADDRESS SUITE/UNIT#
z gyoy "ieirc ihq soe"7J
PROJECT VALUATION ZONING ASSESSOR'S TAR/PARCEL#
$ f�Z 30 q/ & 'a0 - Dc) /
sono.
TYPE OF PERMIT ❑BUILDING ❑PLUMBING ❑MECHANICAL D DEMOLITION 0 ENGINEERING )(FIRE PREVENTION
NAME OF PROJECT re�e�/AZ &// // eIre,e�� GA,���
/
PROJECT DESCRIPTION "� I '/i 7 ,
Detailed description of work to
be included on this permit only
NAME ,y 1/642/0,"
/ PRIMARY PHONE
PROPERTY OWNER ,"s �r�v�x/9G ehty `6 2 h
MAILING ADDRESS
5 33( "-55
STATE ZIP
N3 4t / ►/ 1.i1i'r:it
51 PHONE
s D -' '77.-�-�Z Z
t� MAnnr . Q E-MAIL
v) NTRACTOR — , 7 xI, g3itC.111. 1�t 4�
T �/ The r C �� . FAX
57Z- S7/Z
0 W/I�,STATE CONTRACTOR'S LICENSE# ^ EXPIRATION DATE FEDERAL WAY BUSINESS LICENSE#
-
NPRIMARY PHONE
''' %',v $ u'&#y r-74/#/- 7L 99
APPLICANT ' ',G ADDRESS E-MAIL
/:7 13e,/--4,e,/j g- /1e-� Toy ecuv e,,,x�b.�,S#ri re,Fy ca
,o> �`/ l�.v, �7lo/' FAXAin-
NAME
PROJECT CONTACT 7 o�' (0, De i,1 PRIMARY
e77-974'f
(The individual to receive and MAIIANG ADDRESS E-MAIL
respond to all correspondence /g7 Z y /moo // c 0//e.7. Teo"e0577LG IQ 012/59C10/I15'0y Co
concerning this application) o/ag// STATE
�Dti
FAX
PROJECT FINANCING NAME 0 OWNER-FINANCED
When value is$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 authorised 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 t -11r, as a part of !, ..lication.
SIGNATURE: ' DATE //7 /L
PRINT N , 07 ee S 777/G.t3
Bulletin 11100-January 29,2016 Page 1 of 2 k:\Handouts\Permit Application