14-103079 •
•
CITY CFS PERMIT APPLI ' ,ON��
Federal Way
CITYJUN 22o14
PERMIT NUMBER (4- o__ _ OF FEDERAL WAY
666 TARGET DATE 5
CDS
SITE ADDRESS SUITE/UNIT#
13.4eir s:3
PROJECT VALUATION ZONING ASSESSOR'S TAX/PARCEL#
$ 15' a _aj_ 04 - 0
TYPE OF PERMIT 0 BUILDING ❑ PLUMBING 0 MECHANICAL 0 DEMOLITION 0 ENGINEERING XFIRE PREVENTION
NAME OF PROJECT P2 Z 's v
PROJECT DESCRIPTION �r+
Detailed description of work to r f
be included on this permit only
NAME PRIMARY PHONE
PROPERTY OWNER Pecs sss i'1.),F ZA-14C4 -
MAILING DRESS E-MAIL
34 , Paces i- it `�
CITYl1 W te
(► y
V ZIP CM2V a,
�
PHONE
NAME R--Ry ELE "1 LIC 2S3 - 9-
MAILING ADDRESS i 3 E-MAIL
•
CONTRACTOR 52`x; /3 -�`r i��{ 0
CITY A 6E4,244 ci`,244 •��s'1'T Z I L.Jv� / F J+i GJ J
WA STATE CONTRACTOR'S LICENSE# �� EXPIRATION DATE FEDERAL WAYD ESS LICENSE
Ji I 3 ir7j [�'."J (/2 7
NAME PRIMARY PHONE
NArtA e (-6.34t 14C' e..
APPLICANT MAILING ADDRESS E-MAIL
CITY STATE ZIP FAX
NAM / y �� t PRIMARY PHONEPROJECT CONTACT , A�3N ►'F 1' t 2.53 'GsS I'� -c,
MAILIN ADDRESS E-MAIL
(The individual to receive and 44 IS C" VIZ) /G I S, `s, ,,_,r g_))14,213,1/I 2 1
respond to all correspondence J 4v I'H�4WJr !�!r<O
concerning this application) cITY A Ta,41 ZIP FAX
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 to the city as a part of this app ation.
SIGNATURE: �`d A DATE
Iz 14J
PRINT NAME: 14 4w I
Bulletin#100—January 1,2013 Page 1 of 3 k:\Handouts\Permit Application