15-101282 RECEIVED
. g. gAR 16 201J 10
C,z.oF PERMIT APPLICATION
Federal Way
CITY OF FEDERAL WA*
r CDS
PERMIT NUMBER / < _ / D / ..../.._ '-'"6 _
TARGET DATE
SITE ADDRESS SUITE/UNIT S
Ty% Sc-( (7) VCR__4/4 e-- 5'6 (-%4-% 3 G.-De R4(__ 4,JA_y
PROJECT VALUATION I ZONING ASSESSOR'S TAX/PARCEL S
$ ,,� �� L e� � g ( /3 I/ _ 9 3
TYPE OF PERMIT ❑ BUILDING ❑ PLUMBING ❑ MECHANICAL 0 DEMOLITION 0 ENGINEERING 41 FIRE PREVENTION
NAME OF PROJECT (-._)Un L j Vi S 1 U✓�
12-C
PROJECT DESCRIPTION CaCA-V-6 3 Mofil(tCP‘-i-1 v,J --06.=\//C S
Detailed description of work to
be included on this permit only
NAME PRIMARY PHONE
PROPERTY OWNER l----)Uft.Crl \//S iU-i•--) 7S3 ---`blS - oL1 1
MAILING ADDRESS I.J.�y C-&i..\(N-(�.C�. E-MAIL
--. (-1`�3 L( L-)try �
CITY STATE ZIP
c( U i ‘2:.—7 t.j -
-y t- JJ� ;1 C`.7�^
NAME PHONE
c,ae- SvsrcriS 1--jesr ]tii^L_ 'Z. q3---11Yc(.
MAILING ADDRESS E-MAIL
CONTRACTOR _',61;_i,-, C(-� ,v 50,,Te -(-___.
CITY STATE ZIP FAX
QNcA1cc 1.-5C , °IC-(VL1-1
WA STATE CONTRACTOR'S LICENSE it EXPIRATION DATE FEDERAL WAY BUSINESS LICENSE M
NAME PRIMARY PHONE
c-1 - 5YSt6S I-) SS- 1�� I5--ci33`rZv<C
APPLICANT MAILING ADDRESS E-MAIL
Ce' (44,4.'746,4, N .5,,, " -
CITY STATE ZIP FAX
74C /C'/c__. h 06/1
NAME�7 ��^ /�)/I PRIMARY PHONE
PROJECT CONTACT /h147 1. i7*� 4,14✓--� 15 3 %33` viLf q
(The individual to receive and MaLING ADDRESS p E-MAIL
respond to all correspondence a c.,,,,--r 6c,- R? Ai 5,..,/re---L T`\f-rrc-E. c,RR sySiO is c-x=5--4.,C e-rl
concerning this application) CITY STATE ZIP FAX
1-s4C-/(/C, ' °I%0C-17
NAME ❑ OWNER-FINANCED
PROJECT FINANCING •---,
Required value of$5,000 or more MAILING ADDRESS,CITY,STATE,ZIP PHONE
(RCW 19 27.095)
9 I95 T-" . AUS Cl- 7'6( ik'LC C•/c>L-/c-J P
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 the reliance of the city, including its officers and employees, upon the accuracy of the
information supplied to the city as a of this application. //
SIGNATURE: _/ — - DATE / /'i///C /L/
PRINT NAME: 42 — (''''iez w4 C/,-/-
Bulletin
/,-/Bulletin#100-January 1,2013 Page 1 of 3 k:\Handouts\Permit Application