12-104538 •
S - l d S3
�• RECEIVED
— y
FederalPERMIT
Way SF MF CO ME PL DE EN FP
COMMUNITY DEVELOPMENT S!`XVICIS° 3 2017AP P LI CAT I O N
253-835-2607•FAX 253-835-2609
www.el�orreder�CITY OF FEDERAL WAY
CDS
SITE ADDRESS SUITE/UNIT#
;?)2�3c3 ('Ac-I 1 ;c— � Y , FE VE l' AL. L�.A4i1.yA °leo °-5
PROJECT VALUATION ZONING ASSESSOR'S TAX/PARCEL#
$ 61 . x.6. � 9 7 -. 0q0 - oo
TYPE OF PERMIT ❑BUILDING ❑ PLUMBING ❑ MECHANICAL
❑ DEMOLITION ❑ ENGINEERING .'Q FIRE PREVENTION
NAME OF PROJECT
(Tenant Name/Homeowner Last Name)
E.AST�71Wi� to,NrTr= i_
I Y'3`7T/A ZL I:i cl.,~ /a-i_A V--' A S`-ISTG Lh/- Co''- CZ-7 V ',:c' ''Y Z.
PROJECT DESCRIPTION
Detailed description of work to
be included on this permit only
NAME PRIMARY PHONE
PROPERTY OWNER L.1 I �1�I Iv\ 2,c-3- i 5- �8 1
MAILING ADDRESS E-MAIL
'33'Z 30 PAC)f I I_ I ivy 5
CITY STATE ZIP
• '7_,. .z,-' - r
Ff 11r7 4�/1-i- wA-i ,r.:f, . (J,y k— 5--�i 3 9
NAME PHONE
LI t. 5e a rTt co 2 r l 4-'-.37,-$tib `�C's S(0
MAILING ADDRESS E-MAIL /l
CONTRACTOR ft HOPI '�81 tr /�-Qv- 1- \.a'w. V,a rt'I'�i4�!'I�vX/1iA1<CQYt,
CITY STATE ZIP FAR
Y J-rALLQ;\^ t.:,)', 1'e,•=,7 2 s t, 9, • 6S'-i2
WA STATE CONTRACTOR'S LICENSE# EXPIRATION DATE FEDERAL WAY BUSINESS LICENSE#
L. l i�^.5(11 1 2 r 'I / /
NAME PHONE
"-1-419 4//r� K A/2,ig0Sg'' q'4 -153Co
APPLICANT MAILING ADDRESS E-MAIL
11'44 1 5 7 F A *t_ trn.cli�an" ,��,t-4414s.tbert
CITY STATE ZIP AR
C'',=. 1L-Luc' V.iA 9 8S-13 'z5:s-S3L '-o Li 2-
PROJECT
PROJECT CONTACT NAME PHONE
(The individual to receive and �tl tJlr I I'-#4i'J 14/' ►t(]e-/ 7 2-5>- e ti e- e+5(..a.
respond to all correspondence MAILING ADDRESS E-MAIL
concerning this application) !''-!0' f•-.;;;.7-14- AUl.- KQi "XtiLi,6v�
CITY STATE ZIPAR
P( /l L Lug 1,3f1S E - "l,3-R Lig-0S4/Z
ALTERNATE CONTACT NAME: PHONE E-MAIL
PROJECT FINANCING NAME
❑ OWNER-FINANCED
Required value of$5,000 or more
IRCW 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 suppliedieto the city as/a part of this application.
SIGNATURE: ,414- ��l 4 DATE (t''/.,mss// e--
PRINT NAME: _SC 1•4 P T II Al-1 /i A Z CC i
Bulletin#100-January 1,2011 Page 1 of 3 k:AHandouts\Permit Application