13-105778 •
/ 65774'
CITY OF T • PERMIT MF CO ME PL DE EN FP
Federal WaxMEWED
COMMUNITY DEVELOPMENT SERVICES APPLICATION
253-835-2607•FAX 253-835-2609
ut
www.citoofkderalwati.e*"r A 7 201
SITE ADDRESY OF FEDERAL WAY 411,UNIT#
29 pide/F/Di HG*' $ '. ge4
PROJECT VALUATION ZONING ASSESSOR'S TAX/PARCEL#
$ � �-9Ooo 0 sO
TYPE OF PERMIT ❑ BUILDING ❑ PLUMBING ❑ MECHANICAL
❑ DEMOLITION ❑ ENGINEERING FIRE PREVENTION
NAME OF PROJECT l
(Tenant Name/Homeowner Last Name) J Ods A) Z (5 ,07-T
Ato i2cu poitiOeittr 510/2/of 6C S
PROJECT DESCRIPTION 1 ,p
Detailed description of work to L N 41-e(A) 2 FF7
be included on this permit only
NAME PRIMARY PHONE
PROPERTY OWNER f7/p/Z6-N (J//j/Lf/l < (74;a!y��
MAILING ADDRESS E-MAIL
CITY STATE ZIP
AME PHONE
Ni/RC//�,2 O/J T ?7 g
MAILING ADDRESSE-MAIL
CONTRACTOR 7O S5 Sd 06 v"
CITY STATE I ZIP FAX
i 772-
WA STATE CONTRACTOR'S LICENSE# EXPIRATION DATE FEDERAL WAY BUSINESS JLIcEINISE#
Y? ,'/E7 -/q DR //3 p4-• V-/v/1/61-60
NAME PHO
,m/Ke fyv/RE F7-
APPLICANT MAILING ADDRESS E-MAIL
CITY ,EPF
S T ZIPFAX
PROJECT CONTACT NAME ��� PHONE
(The individual to receive and (')
respond to all correspondence MAILING ADDRESS E-MAIL
concerning this application)
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 application.
SIGNATURE: ���// /�/! � DATE //�� o c./k
PRINT NAME: /772//l' /2.22/9 y c-/G/2 0
Bulletin#100-April 14,2010 Page 1 of 3 k:AHandouts\Permit Application