14-106008 iiimmoi.
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a. or NOV 1 9 za1 . PERMIT PPLICATI
Federal Way
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CITY OF FEDERAL WAY
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PERMIT NUMBER ( �/ _ / L /1 /0 s - F- P
l I _ (J�/ l/ TARGET DATE
SITE ADDRESS
3ZcI1 \Nle e+2ha.e 00 wP+L( S �m
PROJECT VALUATION ZONING ASSESSOR'S TAX/PARCEL# ' _L
$ 1, 513 .00 ! ( 2 1 o 4 - q0 t -
TYPE OF PERMIT ❑BUILDING 0 PLUMBING ❑MECHANICAL ❑DEMOLITION 0 ENGINEERING"'FIRE PREVENTION
NAME OF PROJECT W. ./L 'w a -real C.� ,,!!
PROJECT DESCRIPTION �` do a 6 a," moo t .41/2.4 sj7t to
Detailed description of work to 1 N Roo i \ 21 I
be included on this permit only
NAME
PROPERTY OWNER VM es, -- 5$0344Z PRIMARY PHONE
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NAME-
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CONTRACTOR "'' D��V �orui
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- SA O ORS Eif N DATE F ERAL�AY BUS LI E E#L4 , 1 _ 14.V.1 /US 2a-oto 9 � -
Q LPRIMARY PHONE
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APPLICANT hrtsnarDoksv,
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PROJECT CONTACT rJ at 4-4 M AIL 'ArN 2 R ` 1
(The individual to receive and APDfi 1I 'p _/ 3I 11 !�`'�+ v O
respond to all correspondence ■V`� jJ ej Vat a� e A,�`
concerning this application) l ` X53-
73s-`4114
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NAME 1 •
PROJECT FINANCING
OWNER-FINANCED
Required value of$5,000 or more MAILING ADDRESS,CITY,STATE,ZIP
(RCW 19,27.095) PHONE
I certify under penalty of perjury that I am the property owner or authorized agent of the property owner.I
of my knowledge, the information submitted in support ofthisscertifythat c to the best
all applicable City of Federal Wayg permit application by truetand correct.I certify that I willsnd thatply with
issuance ofthis regulations pertaining to the work authorized the issuance of a permit.I understand the
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,
but only where such claim arises out of the reliance of the city, including its officers and employees, a filede againstathe cthe
information supplied to the city as apart of this application. mp I�Mes, upon the accuracy of the
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DATE 1 l f SIGNATURE: - ` / r f1 �iV-y/L
PRINT NAME: Sint it , A 2 IL h CL v, [
Bulletin#100—January 1,2013 Page 1 of 3
k:\Handouts\Permit Application
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