14-100146 an~oF FERMI APPLICATION
Federal Way RECEIVED
[ � D ( �� JAN 10 2014
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PERMIT NUMBER _ 4 `f✓
_— TARGET DATE CITY OF FEDERAL WAY
CDS
SITE ADDRESS SUITE/UNIT•
e'A1
�i F t c- i- to kit, -fit`( - z o /
PROJECT VALUATION ZONING ASSESSOR'S TAX/PARCEL S
3,S - d 0 ' _ c7 / O 6
TYPE OF PERMIT ❑ BUILDING 0 PLUMBING 0 MECHANICAL 0 DEMOLITION 0 ENGINEERING I FIRE PREVENTION
NAME OF PROJECT -To H N L , 5 co ti-
PROJECT DESCRIPTION
.r-o Q t-ocorm' c_el Pere Pc 4" a.‘
Detailed description of work to �l STI A g P t0,6A'1_,4 S"r I j Ir M.
be included on this permit only
NAMEPRIMARY PHONE
PROPERTY OWNER N-I �S G'''1 Z n v6 Ser, /Ile t` " f Pp D i -'7G0J- 67,-0 e!
MAILING ADDRESS E-MAIL,
3,{6 1s; G LA, i _CITY
s;ATE ��pp
/ti Vt: ST zo,l77
NAME PHONE
Pl c P R-07 e t o", 3.410 -9 600
ADDRESS E-MAIL
CONTRACTOR
MAILING1 3 o (0 l USO/! e tree 47rLE.
CITY STATE ZIP AX CO 14.%
iZ• r 9' i y (e 1- 717- tis-Y6
WA STATE CONTRACTOR'S LICENSE$ EXPIRATION DATE FEDERAL WAY BUSINESS LICENSE it
ict ge -*-oz c ,i- L - /I 3 //y Zv--oc 'l o2'-/1y-oo �L
NAME F i P PPHONE
t— c.r1,0., ¢ PRIMARY 29 a --16 o
APPLICANT MAILING ADDRESS EMAIL
-'—1 3 c) co ( i JOA lee°0 e Prs 17 LE
CITYSTATE ZIP FAX M
e TT 7 t..4 q'zi- 7r)- y6
NAME PRIMARY PHONE
PROJECT CONTACT VA-4) Yter- 291)--9 vo
(The individual to receive and MAILING ADDRESS E-MAIL
respond to all correspondence 17 o 6 /2)0/1 /e-o i?-00e re-14- -c Cb 1
concerning this application) CITY STATE ZIP FAX
2A0
PROJECT FINANCING NAME 0 OWNER-FINANCED
Required value of$5,000 or more MAILING ADDRESS,CITY,STATE,ZIP
PHONE
(RCW 19.27.095)
I certify under penalty of perjury that I am the property owner or authorised agent of the property owner.I certify that to the best
of my knowledge, the information submitted in support of this permit application is true and correct.I certify that I will comply with
all applicable City of Federal Way regulations pertaining to the work authorised by the issuance of a permit.I understand that the
issuance of this permit does not remove the owner's responsibility for compliance with local, state, or federal laws regulating
construction or environmental laws.
I further agree to hold harmless the City of Federal Way as to any claim(including costs,expenses,and attorneys'fees incurred in
the investigation and defense of such claim),which may be made by any person,including the undersigned,and filed against the city,
but only where such claim arises out of the reliance of the city, including its officers and employees, upon the accuracy of the
information supplied to the city as a part of this application.
SIGNATURE: DATE ///7
PRINT NAME: /7A7, //$J
Bulletin#100—January 1,2013 Page 1 of 3 k:\Handouts\Permit Application