17-103375 PERMI PPLICATION
CITY OF '
Federal Way PERMIT CENTER.0 nue South+ Federal Way,WA 98003-6325
253-835-2607+ FAX 253-835-2609+permitcenter(dcityoffedera1way.com
J U L 13 2017
PERMIT NUMBER 1 _ 1 V 3 3 .� _ CITY OF FEDERAL. E )j
�MMUr ` ilia' ATE
...._ ____
SITE ADDRESS SUITE/UNIT#
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0 1 Jay r\OCI-QASt2 r \N cuk ).\3\--\/-\ 0 if<
PROJECT VALUATION ZONING ASSESSOR'$ AX/PARCEL#
,-,2_ ,,2_, \ (-, LI _ 9 I
TYPE OF PERMIT E BUILDING ❑ PLUMBING ❑ MECHANICAL ❑ DEMOLITION ❑ ENGINEERING N' FIRE PREVENTION
NAME OF PROJECT ' , 1oyl�cJ, AT
%..\ (51A — -Y\O
PROJECT DESCRIPTION ��//�� �
Detailed description of work to T�JC Q 0 C rl k ) \r- 1r\ 'p
be included on this permit only ,/7 .� �� ) �,` S ` % 1
`(mac t`ry r\rc h' Xr'1 �- �NQ -
NAME \J
( PRIMARY PHONE
U -DOY--\C\ J \ C 1 D 2s-3 - -- - l 1 $4
PROPERTY OWNER ING7ADD ic � �,._ E-MAIL
CITY STATE �F
PHONE
1 Fl b(� s\u\AS 2,4- 0-�1�.--1502
MAILING DRE88�` ,q-��� +� E-MAIL �, ��(� ��,,��
CONTRACTOR ��—t 6 � v� \V� �c�\�� l� tom,,,,cLair \"`-' ( .kgfe'SI.Q���+
1.17
� Q k�14` WTD �1 sir 2_ FAX
--1-1.- -` 504 �1�1
WA STATE CONTRACTOR'S LICENSE# EXPIRATION DATE FEDERAL WAY BUSINESS LICENSE#
E PRIMARY PHONE
ITr Mea- t"l ' 31.6 1.l.lt1 - i \.a -.
APPLICANT LING ADDRESS E-MAIL
to� g�\r'd Ave 0 .(._.�C(� \cacear C nv,� e�9s ,rxs'cpm
V11� STATE\ )(� t �j'� FA'` 1. i -' fl -�. C-1v44
NAM PRIMARY PHONE
PROJECT CONTACT \C3 \ \ <U-t ,),uq- 1^1 d ,�Q 4)—
MAILING ADDRESS
(The individual to receive and f ` ,,moi E-MAIL
respond to all correspondence '�? 9(--1 $ `� y,oa(ur'\`"" 'v" (esk sk,
concerning this application) C STATE ZIP FAX
NAME
PROJECT FINANCING ❑ OWNER-FINANCED
When value is$5,000 or more MAILING ADDRESS,CITY,STATE,ZIP PHONE
(RCW 19.27095)
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 supplie to the city as a part of this application.
4
R -/ ►_.i _ - '- 13- 1 �
SIGNATU f/ // DATE
PRINT NAME: Eh , k C f( � V V C
Bulletin#100—January 29,2016 Page 1 of 2 k:AHandouts\Permit Application