12-100653 fr2--_- I OO 653
SF MF CO ME PL DE EN
Federa�Wa [AEcEiv et3 PERMIT cFP?
COMMUNITY DEVELOPMENTS CES 0 13`�2 APPLI CATI O N
253-835-2607•FAX 253-835-2609 `;/
www.cihio((ederaiway�o," FEDERAL WAV!
CITY of
SITE ADDRESS CDS SUITE/UNIT#
'17 77 77-a-v I b.4-' WC`bN Sa u'(tj- FI09�t~t-1x- 6 r-'lar 'V J A' 56 b c' i
PROJECT VALUATION ZONING ASSESSOR'S TAX/PARCEL#
$ i e 0,2 0 L -L 6 6 J - v Z. S
TYPE OF PERMIT ❑ BUILDING ❑ PLUMBING ❑ MECHANICAL
❑ DEMOLITION ❑ ENGINEERING ,FIRE PREVENTION
NAME OF PROJECT
(Tenant Name/Homeowner Last Name) Vitv en,c.rElliO 3 LL(,-
PROJECT DESCRIPTION
Detailed description of work to F S'N ik I N 'fixL I Al kr e\lsl s f 1;1 N 1e-Len- $ y�S'C�M T-2,be included on this permit only )r0,1- -,-- Lvt_
- _
NAME PRIMARY PHONE
PROPERTY OWNER [,>/bP.,( Nitl 11 (-42,5")-2.)-16__ 6i 6t)
MAILING ADDRESS E-MAIL
Ii 4-5-c NE 6,14-1.1 G V-, lou' 3. Qro�tvho tires-.
CITY STATE ZIP
(2rc040411-,w7) WP- 5155c'
NAME PHONE
et 12:e 6--.5 --74,1 W�•-r' 14 c- 2 3 'z '3-- I'2--‘i 8
MAILING ADDRESS E-MAIL
CONTRACTOR - CI& r�14 ) ti Claes'CS'rf''a n
i,l, r.. ..a0l
CITY STATE ZIP FAX
ei.0 i v 414. O t,D‘ri -2-s7, — -13s7--z..,ft
WA STATE CONTRACTOR'S LICENSE# EXPIRATION DATE FEDERAL WAY BUSINESS LICENSE#
F-t s' ii FL,.t'.3 12- / l( / az- l4S1ooar�1�+ u4i.
NAME_.....,�- Y(-� V5-2,)6t3 _ 12`-te
APPLICANT MAILING ADDRESS 1a E-MAIL) ----,r i
2.4.,E roan Th 1 C PK '`I STATE ZIP v!o J ( 7/K y K►L.-1 ad"l'•L.:,,...
CITY
0t> W11" )0C-)---r1 (2 r 3)13 - 113
PROJECT CONTACT NAME i PHONE
(The individual to receive and Gci v i'. w} (2.-c 1 ) QS 3; (21 j
respond to all correspondence MAILING ADD17,,SS I E-MAIL J�Cri
cAr
concerning this application) 7� '� lai�)� /tS41J i(yaal CO w,
CI STATE ZIP FAX 1
ti.2•�ti w, )0 c' -t-1 (zs- ) '1 bs- 1 13
ALTERNATE CONTACT NAME: PHONE E-MAIL
PROJECT FINANCING NAME
❑ OWNER-FINANCED
Required value of$5,000 or more
(RCW 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 t - city, including its officers and employees, upon the accuracy of the
information supplied to the city as a part of this applic, ".n.
SIGNATURE: r -
DATE 2/6/17/
PRINT NAME: `
Bulletin#100—January 1,2011 Page 1 of 3 k:AHandouts\Permit Application