16-102122 ill
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CITY OF
Federal WIRECEIVED PERMIT SF MF CO ME PL DE EN FP
COMMUNITY DEVELOPMENT SERVICES AYAP PLICATION
253-835-2607*FAX 253-835-260.9 O A T O CU
SITE ADDRESS CITY OF FEDERAL WAY
S �2 f oDs . SUITE/UNIT#
\a er►ilii6U ,r lroCA(� CJ �(t, o2CJC7 o2 OO
PROJECT VALUATION ZONING ASSESSO*S TAX/PARCEL#
$ (2( 00°
a t 544- 0 (0 - cv v _
TYPE OF PERMIT CIBUILDING ❑ PLUMBING ❑ MECHANICAL
❑ DEMOLITION ❑ ENGINEERING J FIRE PREVENTION
NAME OF PROJECT
(Tenant Name/Homeowner Last Name) D 5 --\C T ` U
PROJECT DESCRIPTION
Detailed description of work to �W 5 -c ` rC �`kUr✓-\ ,5 rv\ } Co e= e' Ytc J T .
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be included on this permit only
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NAME ...PRIMARY PHONE
PROPERTY OWNER /'() k/e�i�'W`-5 j `U LL '
MAILING` ADDRESS \ E-MAIL
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CITY STATE ZIP
tAN'%rv,,w.n Z ,As q'Y 03 3
NAME
PHONE
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MAILING ADDRESS E-MAIL
CONTRACTOR g02s- WuH,n`2 " 4,,,,,4_, 5 c1( u.s(_,.,„ i eoiSe(.eci-- - ,w'-
CITY J STATE ZIP FAX LJ -cn
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WA STATE CONTRACTOR'S LLICENSE# EXPIRATION DATE FEDERAL WAY BUSINESS LICENSE#
'
NAMEPHONE
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MAILING ADDRESS E-MAILI'
APPLICANT
CITY STATE ZIP FAX
PROJECT CONTACT NAME T PHONE
(The individual to receive and ` SC, 5 Cu n((H c c.r J U b %r1 3 5(�l fs��
MAILING ADDRESS
E-MAIL
respond to all correspondence
concerning this application) U 51—nc�(Qt sen-c1 e c-4t'., 0-v-4--
(
CITY STATE ZIP FAX [
ALTERNATE CONTACT NAME: PHONE E-MAIL
PROJECT FINANCING NAME
0 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 the city, including its officers and employees, upon the accuracy of the
information supplied e city as a part of this application.
SIGNATURE: cwy DATE g/4/r67
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Bulletin#100 January 1,2011 J Page I of 3 k:AHandouts\Permit Application