16-102994 CITY OF -"`rr/ ECEIVED PERMITAPPLICATION
/
Federal Way JUN 2 0 2015
F RE
1
Cj',- OFE AY
PERMIT NUMBER f v ! C S Alp
I TARGET DATE
SITE ADDRESS SUITE/UNIT#
9 8r )7 A.cv ; c_ Hv/ 3 acct .
PROJECT VALUATION
ZONING ASSESSOR'S TA4PARCEL M
$ ) 8'6 o 1 5 0 0 5 0 - o / / Z)
TYPE OF PERMIT 0 BUILDING 0 PLUMBING 0 MECHANICAL 0 DEMOLITION 0 ENGINEERING (FIRE PREVENTION ---
NAME
NAME OF PROJECT L ee eri day,/ )7C v)� �
PROJECT DESCRIPTION
/1),07 IA/ /�' Q r} 1�e 57-i rz'/' l LLPa C�
Detailed description of work to
be included on this permit only
NAME PRIMARY PHONE
6! en n, 1) ozA9kaiinis
PROPERTY OWNER MAILING AD, - --S E-MAIL
CITY STATE ZIP
NAME - PHONE ..
J- -'a i it i Y )9)--c..-C_-e-)"- 2c 222? -5-2 1-1
E-MAIL
MAILING ADDRESS j
CONTRACTOR 9/ J z7 +'/ �l iI 1YD,i I'-S 0 4Y Sk...0-)
Ohir G-4--
CITY STATE Z/�U+�?/�r - FAX
/
WA STATE CONTRACTOR'S LICENSE* 1417lEXPIRATION DATE FEDERAL WAY BUSINESS LICENSE#
)- rcir))te S' CO (12 / 92,-/
NAME PRIMARY PHONE
F,,r k coo.)-i- 1 ��4-1�- ,
2 ` 21/2
MAIL G ADDRESS
APPLICANT E-MAIL.v -MCITY`z "/��/'. ) q°-1'4 it/f
ZIP FAX
NAME PRIMARY PHONE .. ._.
PROJECT CONTACT
(The individual to receive and MAILING ADDRESS ' `:- E-MAIL
respond to all correspondence
concerning this application) CITY STATE ZIP FAX
NAME
PROJECT FINANCING
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 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 ity as a part of this application.
SIGNATURE: ,, DATE r- h.o 'rb
PRINT NAME: . r fir_ A
Bulletin#100—January 4,2016 Page 1 of 3 k:\Handouts\Permit Application