12-104004 RECEIVED _ _ - 1 0 4 0 0 -
carr of
Federal Wa+UG 2 9 2012 FP PERMIT SF MF CO ME EL PL DE EN
CO WN o;.F Rbyg+ FEDERAL ,PPLICATION
www.cityoffederalway.com CDS
1177.:T77.77-ii K71.. :1175-7 13171117K-;
SITE ADDRESS
3'/3.= IAA1
SUITE/UNIT# ZONING ASSESSOR'S TAX/PARCEL#
22 a oma( - of 0 0
NAME OF PROJECT
(Tenant or Homeowner Name) G1,t7A?2) 1/I 5/aL) (P1-214 E• 7-) C„L)6
❑BUILDING ❑ PLUMBING 0 MECHANICAL
TYPE OF PERMIT
0 DEMOLITION 0 ELECTRICAL 0 ENGINEERING FIRE PREVENTION
R,t✓4%/:E P6A/i7i_=,A' w/i7H <f�"fzc� SAP.- DROPS TAA.;Al
O A)
PROJECT DESCRIPTION �f�li./AJC -%-1L,F_ 4- 7T 7(Q O VkWC
Detailed description of work to
be included on this permit only
s
NAME PRIMARY PHONE
PROPERTY OWNER ( ) -
MAILING ADDRESS.CITY,STATE,ZIP E-MAIL
OWNER IS ALSO: ❑ CONTRACTOR 0 APPLICANT 0 PROJECT CONTACT
NAME PRIMARY PHONE
�rpE2u> / /R4 PROTE.c;Tk0+u (cSs ) L ; - 7710
CONTRACTOR
MAILING ADDRESS,CITY,STATE.ZIP ,,/,/) tZ6';, FAX
5//9 f'/ FC7soiG fC D� Ai>a/ `rt *3135 5--/73s (ZS5 ) f3sa - ;WIC
WA STATE CONTRACTOR'S LICENSE# EXPIRATION DATE FEDERAL WAY BUSINESS LICENSE#
5"PC ''1-Ply//Ls /Z
NAME
HONE
01/16k) �,9,?/..✓k; (3') ) e'PR2IIN9�RY /7
APPLICANT l /c
MAILING ADDRESS,CITY,STATE,ZIP FAX
yrs ( )
PROJECT CONTACT NAME PRIMARY PHONE
(The individual to receive and 6-4k-'h Wt`'"U (�E4 )7_,.1 - /-77.04x:
respond to all correspondence MAILING ADDRESS,CITY,STATE,ZIP FAX S/ n.
concerning this application) , 1i/Z•, ( ) -
ALTERNATE CONTACT NAME: PRIMARY PHONE E-MAIL
PROJECT FINANCING NAME
0 OWNER-FINANCED
Required for projects with
value of$5,000 or more MAILING ADDRESS,CITY.STATE,ZIP PRIMARY PHONE
(RCW 19.27.095)
( ) -
I cert(fy 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 supplied to the city as a part of this application.
SIGNATURE: DATE07 9
PRINT NAME: 'L4 1 Oz✓ .A_J
Bulletin#100—4/21/2009 Page 1 of 4 k:\Handouts\Permit Application