13-101937 7
RECEIVE 4 e p p . f�D • ( nI 9
3
oF �� Y p 2 2013
Federal W PERM SF MF CO ME EL PL DE ENUP)
COMMLOP FEDERAL APPLICATION
253-835-2607•FAX -35-2609 CDS
www.cityolfederalwau.corn
SITE ADDRESS
S9 83'/ 6,,b /Z isiAE:cry Z t-"? i .5-01177-/
SUITE/UNIT# ZONING ASSESSOR'S TAB CEL# /, 9 0
NAME OF PROJECT /
(Tenant or Homeowner Name) t A IZL ? (�+iS/Oki i't06- 'I 1 A/,l
❑BUILDING ❑ PLUMBING ❑ MECHANICAL
TYPE OF PERMIT
❑ DEMOLITION E ELECTRICAL E ENGINEERING SVFIRE PREVENTION
ADD (ob) PA 4117' ,quo ,eXtcx.-.,A�t�
PROJECT DESCRIPTION ,t) NE SvAL.
Detailed description of work to
be included on this permit only
..T Zoo VAt.v1
NAME _._. PRIMARY PHONE ..
PROPERTY OWNER ( ) -
MAILING ADDRESS,CITY,STATE,ZIP E-MAIL
OWNER IS ALSO: Ej CONTRACTOR El APPLICANT Ei PROJECT CONTACT
NAME PRIMARY PHONE
-71>E7,0k+x t-/RE, sr (553 ) 353 - 7780
CONTRACTOR MAILING ADDRESS.CITY,STATE,ZIP f/xaFI:d FAX
/L/ P-" rE9seD101e NW # `133-3s. (ZS3 ) B53 - S-090
WA STATE CONTRACTOR'S♦LICENSE# EXPIRATION DATE FEDERAL WAY BUSINESS�cLICENSE{� #
S c_
/Al FPCV/ .. /2 / 3' / °f -' hid i L...t( ^fly. , (�('\�.17x1
NAME yPRIMARY PHONE
�`
APPLICANT ,ge 7 0 (lin ) zz,/ - /766
MAILING ADDRESS,CITY,STATE,ZIP FAX
- <?1.- It.
PROJECT CONTACT NAME-�1 PRIMARY PHONE
(The individual to receive and ri+9,�Y 4L✓- _ (.160 )ZZ? - 0 j
respond to all correspondence MAILING ADDRESS.CITY,STATE,ZIP FAX
concerning this application)
ALTERNATE} �
CONTACT/ NAME: PRIMARY PHONES � E-MAIL
+�/`r.t ,'r-�^,.?, ("7..J..� ) 0:-S - '7N��'y�y .�lcz /'/frZP'.
PROJECT FINANCING NAME
OWNER-FINANCED
Required for projects with
value of$5,000 or more MAILING ADDRESS,CITY,STATE,ZIP PRIMARY PHONE
(RCW 19.27.0951
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 clairtt es out of the reliance of the city, including its officers and employees, upon the accuracy of the
information supplied to the cit part oft is application. QQ
SIGNATURE: DATE 9/1-e---.
PRINT NAME: (] i' . ✓
Bulletin#100—4/21/2009 Page 1 of 4 k:\Handouts\Permit Application