16-102294 CITY OF RECEIVED
Mar 1 �' `j16 •
PERMIT APPLICATION
Federal Way CITY OF FEDERAL WAY
CDS
1
PERMIT NUMBER 1 (0 _ I 0 2 2- / (/ _ F TARGET DATEpp')
LLL
SITE ADDRESS SUITE/UNIT#
3.5108., cL.cif c_. k-kuiy 5 �e�lzri:,\ VJc,y c1 E 00
PROJECT VALUATION ZONING ASSESSOR'S TAR/PARCEL#
$ 11 (a0U --" 1 5 o 5 6 _ 0 0 / 1 0
TYPE OF PERMIT ❑BUILDING 0 PLUMBING 0 MECHANICAL 0 DEMOLITION 0 ENGINEERING ErrIRE PREVENTION
NAME OF PROJECT 14 4 522-
CeAe,\Drc0\-\()WS \,-e tV\c)-C/•.vty ovNO 5
PROJECT DESCRIPTION IeActy, T`"^Q i'OV-t w12-ii V0 cjC� ,AOk 1 F ,.c.L ov, )-
Detailed description of work to A.ddlr.e sa b le rn9eljV5 V 1'1 OA\4-Or \r1
nocX S i1�Q v i \
be included on this permit only a„� AC-
NAME l 1 PRIMARY PHONE
PROPERTY OWNER Fcorc jt C.o;��r ‘ \ho') Zo C,-- Z55 -(i etMAILING
O 1 J B Z33RG V\ Se E-MAIL
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NAME �IV\bk-e)N A\'W4,M PRONE 3 --lb
ou
Z�G� _Jz -
MAILING ADDRESS Ap E-MAIL �}
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CONTRACTOR -1-0V � J��,reur-F lMt.y /7 Q�,10-5N)J, ,,mSr0 are,.:0.,
ZIP
e,��k-1� / W STATECITY �. c3t 3t-1 FAX
-3z7--1-z i 4
WA STATE CONTRACTOR'S LICENSE# EXPIRATION DATE FEDERAL WAY BUSINESS LICENSE#
/ /
NAME _. Y
MARY PHONE
\`^aw e\ grv`ACtS ` PRI0 its Z 0 fo -4 3 6 - 5 3 3 L
MAILING ADDRESS
APPLICANT E-MAIL `
1-0 AIrP9ir1 w4 t 5 9,2.rr1a-5@oa5kia5k.o.w.cittA.u�M
CITP FAX
Y,
Vkkt_ w TA Z 9 GI l i t Zv 6 --- -z- --i--2 1 y
PROJECT CONTACT NAME 1_\�AvG` V rv�l tt5 PRIMARY PHONE 1-
Lob-L-1 3 5��3
(The individual to receive and MAILING ADDRESS ,,..., , E.
respond to all correspondence 1 Z ii r 01,0 V:'- .l./1 ce y 5, > Qerr7 i ) wa5 Jy�, 46,, ,(o(..,
concerning this application) CITY STATIc ZIP
fjelnAk.k� •a FAX 'l-z-Z-Ittli
NAME
PROJECT FINANCING El 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 L - ou • the reliance of the city, including its officers and employees, upon the accuracy of the
information supplied to citoft, - - ,,z-,7",,- n.
SIGNATURE: 0
`'.0- DATE 5—k2—7,0
ZU Ip
PRINT NAME: \`i`Ctvnvew\ 0r thday A4CTC6
Bulletin#100-January 1,2013 Page 1 of 3 kAHandouts\Permit Application