14-106179 •
a •
amoF < 1 0 f PERMIT APPLI ,�C,A,�TION
Federal Way CIV
DEC 0 3 2014
PERMIT NUMBER ( 4- _ ( _ CITY OF FEDERAL
TARGET DATE WAY
CDS
SITE ADDRESStl 3a). SUITE/UNIT.
3)a-9-5!` PPrc.;7.(- 1--- AIA. Fe - C/1-1 Lil y as
PROJECT VALUATION ZONING ASSESSOR'S TAR/PARCEL#
$ /j GYM CC - t= ! S b . o s o - a / /^0 0
TYPE OF PERMIT 0 BUILDING 0 PLUMBING 0 MECHANICAL 0 DEMOLITION 0 ENGINEERING lld'NIRE PREVENTION
NAME OF PROJECT I ' l l)6 t✓ �L 0 A v1 t -I VIA r r- e. % �-
A ���) / Q.e,.1cam: .\-c.._ �; ,r AI,Ar ✓1&fi ,,,i, -4-,J -
PROJECT DESCRIPTION /� / ��
Detailed description of work to 0 Ct,�b 4.1--g4.1--gp f 0/)vv . t...k3 0 n L'c_ \1 /�` U `ez-J a.),..._ i-
be included on this permit only 'j f" -1-1 ficc 5*,`N P/1-4:- P
NAME /nPRIMARY PHONE
PROPERTY OWNER i AZ S C H ._i--y- In 1/0S-1-M e v1 1._{._ R(t1•. 1-0,s- G '7 13
MAILING ADDRESS E-MAIL
//a-t s L.j .S-r4 I >41,4,,,1 5,t 5th Flet,
or 6 STATE ZIP
NAME PHONE
F► to Frc.,,tccA;. cti In t1e), - mo ?boo
MAILING ADDRESS BAIL C' i 1.
`e i4 e ms
CONTRACTORiiu ( J A
CITY STATE tiPz _ FAX
WA STATE CONTRACTOR'S LICENSE M EXPIRATION DATE FEDERAL WAY BUSINESS LICENSE A
F S Z f A P1-"- o��/1�Y,,�I 1'1'1 L /21 /.5- �-e) 00-iioc�a`i?4(-0a GI--
NAME
IP�, i✓I i `( PRIMARY 4. !o l(Joc
APPLICANT MAHdNG ADDRESS iF
; 6 . no r .J FPS ', b-i 1 r. ct,vs,
CI STATE ZIP FAX
ue4� L,,,A i3.)-()"t ‘,? s- 35s 1154/6
NAME1 f�/� PRIMARY PHONE
PROJECT CONTACT /�LP',Z) P . l 0 L(a--5 cx9 e) - 260 0
(The individual to receive and MAH.INO ADDRESS E-MAIL _
respond to all correspondence I-7- 0 6 • `. 12) DAv,d c FPJ. 'L tfit•L oi,-k
concerning this application) cI I Y,, U e (STATE/E ZIP cis? iL FAX
NAME
PROJECT FINANCING 0 OWNER-FINANCED
Required value of$5,000 or more MAILING ADDRESS,CITY,STATE, 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 o h claim), which may be made by any person,including the undersigned,and filed against the city,
but only where such cla art s out of the reliance,gfthe city, including its officers and employees, upon the accuracy of the
information supplied to the as a part of this cation.
SIGNATU / n U L V, DATE /a( /A e"
PRINT NAME: .04 1)16 (,.,_J
Bulletin#100-January 1,2013 Page 1 of 3 k:\Handouts\Permit Application