13-105324 ����► 052.844 • PERMI'IIAPPLICATION
Federal Way RECEIVED
PERMIT NUMBER 1 - 1 0 ✓ 3 `/— FP '``6 Y 2 7 2013
— i TARGET DATE
CITY OF FEDERAL WAY
SITE ADDRESSSUITE/urh .lS
Z695 17 a try s
PROJECT VALUATION ZONING ASSESSOR'S TAX/PARCEL#
$ 10, l - I 5- 00eo - o1 10
TYPE OF PERMIT ❑ BUILDING ❑ PLUMBING 0 MECHANICAL 0 DEMOLITION 0 ENGINEERING IL [R
N' E PREVENTION
NAME OF PROJECT l Q i CA V)i'ta bq.41 do Cent
PROJECT DESCRIPTION `ng(�(c`11 Gcldress�ble Tr�eA1Gtm �"1-" RCti4it�CNA1011 f�
Detailed description of work to t1 1 C44 \ (a11nQ SOi}�I COA neck +t? eXI n(' 6' c1 hkler C6tcp 5 ill ( T
be included on this permit only C+ ` k ter Jev ( 65kt L(ne.
�U�, ixll`J, l 0(1(`C�:Gt 4o new �C6�n � (I,�S ��1
NAME i PRIMARY PHONE
PROPERTY OWNER HarSC1I "1�a 9co)ect(e$
MAILING DRESS �lJ E-MAIL
.o‘ box `x'70
CITY STATE ZIP
I?oc�l�.nd tW- �72b�
NAME E
WC4Shi nc`}0 r/ 'm LY`c• PH V 3ZS'AZW
MAILING ADDRESS J E-MAIL
CONTRACTOR 2030 Al rPrn+ -/ J` (1'Icikit i 1(+ WC iWK GI�IIYAc
orn
CITY% C.kite �ITj1 ZIP /1jy l 1.4 F
`�{i) �Vll `1lXV X0(-322-'721y
WAS\ ASI-���'3 I,ICgN3� � EXPIRATION DATE FEDERAL WAY BU$INES3 LICENSE#
2 17- 0S' 13 20-00.101 2.9-06-111,
NAME PRIMARY PHONE
)ft1E AS Co'17'RAcTarz.
APPLICANT MAILING ADDRESS
E-MAIL
CITY STATE ZIP FAX
NAME '/ P MARYePHONE
PROJECT CONTACT I1 Q�rr` I�C 1-t(�L In I\tcx J kkcw It J�� 3Z '
d
(The individual to receive and MAILING ADDR./s�
3o A
respond to all correspondence Ctj('� C.-.I ' . L�L�1(;i 1 tic in( c‘kr,l f11A1
concerning this application) CITY STATE ZIP FAX
kle WR %I-3H 206-37.1-'12.1g
NAME
PROJECT FINANCING 0 OWNER-FINANCED
Required value of$5,000 or more MAILING ADDRESS,CITY,STATE,ZIP
(RCW 19.27.095) 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: <G✓Z �(�^ DATE I( //–P7-` ( y 3
'/ Ir/ -
PRINT NAME: I�(,L.1 f\
Bulletin#100-January 1,2013 Page 1 of 3 k:\Handouts\Permit Application