14-105953 RECEIVED
4100V 14 2014
�,rroF ""kPERMIT I PPLICATI N
O
Federal Way CITY OF FEDERAL WA'1
CDS
PERMIT NUMBER- / I/_ + lll.../ / 5 9 5 3- r P'�/ / TARGET DATEAil/A
SITE ADDRESS SUITE/UNIT#
3' 2 2 S PA-c-4,1-71,c_ kw Li c , Zr2
PROJECT VALUATION ZONING ASSESSOR'S TAX/PARCEL#
$ &Vt , 2-C t 5 e C i 0 - 0 t c:) 0
TYPE OF PERMIT ❑ BUILDING ❑ PLUMBING❑MECHANICAL ❑ DEMOLITION E ENGINEERING-' FIRE PREVENTION
NAME OF PROJECT --r—_ M �'z a ,Lt
•� '
PROJECT DESCRIPTION C IJ.i:M 1.--)Ci i %i '4 C 'I; +( P4-'7 C'. ,ry yL ai s w..S j 4 -"1,
Detailed description of work to I _ ,-i 4'C 4 "` t Q d 1'+' L i✓,t.:. ' ' 9-1 C L7 L / li w;
be included on this permit only 9!V 4 >
NAME
�j �1, PRIMARY PHONE j, /
PROPERTY OWNER t'r-'�;�SL.1-1 1'44L�51 B✓l C Nal t� c+ K2 - 42,_c • `f/c.'Wt ` ! l 3
MAILING ADDRESS E-MAIL
1 1 (7I/v 5 or L.r L 4 Iv 57 I P ',e=1t4 tjF
CITY STATE ZIP
NAME PHONE
MAILING ADDRESS E-MAIL
CONTRACTOR
'7 q 5' 'S .. 2D O'vl Ct
CITY q� i.. STATE ZIP FAX
K--t:)\1 t" /+ 9 c s ii=i -- ' 1Z 4Z "?_3
WA STATE CONTRACTOR'S LICENSE# EXPIRATION DATE FEDERAL WAY BUSINESS LICENSE#
/?1t(;.,-1 1 7 k`=I p c 41 c t. f5 2-0 Uc --l o‘4 c, s - 00- V L
NAME V f*^) PRIMARY PHONE LL
APPLICANT MAILING ADDRESS E-MAIL `
CITY STATE ZIP -q v Lw"&CVCII.[./
C 0 Act-J.#-0 t✓
sgl.✓1
NAME PRIMARY PHONE
PROJECT CONTACT
(The individual to receive and MAILING ADDRESS E-MAIL
respond to all correspondence
concerning this application) CITY 1 STATE ZIP FAX
NAME
PROJECT FINANCING ❑ OWNER-FINANCED
Required value of$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 city as a part of this application.
SIGNATURE: J.--(7) .-----"\_-i.--- DATE i 1 /( 4-/ 1 4
PRINT NAME: 1 C,J e`-IV
Bulletin#100—January I,2013 Page 1 of 3 k:\Handouts\Permit Application