12-104291 RECEIVE* _ 1 0 4 2 9
Federal v®F a.I 9 2012 WaySEP PERMIT SF MF CO ME PL DE EN P
F1
COMMUNITY DEVELOPMENT SERVICESCE�cC D E n^Ap P L I C AT I O N
253-835-2607•FAX 2536P.V rC IVy
rituolleeleralu'u t t CDS
SITE ADDRESS SUITE/UNIT#
3 2 0 75- C- 171�,� I ��� _-
PROJECT VALUATION ZONING ASSESSOR'S TAX/PARCEL# O 5-O -
TYPE OF PERMIT ❑ BUILDING CIPLUMBING ❑ MECHANICAL
❑ DEMOLITION ❑ ENGINEERING FIRE PREVENTION
NAME OF PROJECT 7,oSS i>pL
(Tenant Name/Ilomum
eoer Last Name) z-5SL�
PROJECT DESCRIPTION •� 5 p/�1211^t4 LC lie-
Detailed description of work to Ir -Db �G1 �b 1�..) �}-p l2.- 1i"'1A GGA t .et /CV et d
be included on this permit only t . � 1
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NAME PRIMARY PHONE
PROPERTY OWNER ? 61-611fr SSS
MAILING ADDRESS !"- E-MAIL
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CITYs_etiti tin �'�" STATE ZIP 6, /-�
aG
NAME /n� PHONE
r2 - CovI r h.x �, w.-1 2S3-S72--7227
MAILING ADDRESS ,�,,,,,,(� E-MAIL
CONTRACTOR�� 8s s zb4Z ��CI"c" (Ltc. Ge_ ecN w.COW,
p\ CITY STATE ZII FAX
' it• - `78a 3 Z 253 43,72
WA STATE CONTRACTOR'S LICENSE# EXPIRATION DATE FEDERAL WAY BUSINESS LICENSE#
1c11 b2 4 i t / r 3 Ott.-t,o1 413 -ori y3L
NAME PHONE
SA vwt
APPLICANT MAILING ADDRESS E-MAIL
CITY STATE ZIP FAX
PROJECT CONTACTPHONE
(The individual to receive and t Z t Gl L \Itt�Or� Z 5-3-f3�2 72 Z 2
respond to all correspondence MAILING ADDRESS E-MAIL
concerning this application) SAY17 e
CITY STATE ZIP FAX
ALTERNATE CONTACT NAME: PHONE E-MAIL
PROJECT FINANCING NAME
OWNER-FINANCED
Required value of$5,000 or more
(RCW 19.27.095) MAILING ADDRESS,CITY,STATE,ZIP 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 applica ', .
SIGNATURE: / "A( / / DATE // "Z _
PRINT NAME: / IC /� (/i//..y ,
Bulletin#100-January 1,2011 / Page 1 of 3 k:AHandouts\Permit Application