15-104871 A
�.artOF • PERMIT SPPLICATION
Federal Way RECEIVED
7 i
_ SEP 2 4 2015
PERMIT NUMBER '� ( a
— — - - TARGET DATE CITY OF FEDERAL WAY
CDS
SITE AD
DRESS
SUITE/UNIT#
35 82.0 \j FJHAuS .,n. Guru / s
PROJECT VALUATION ZONING
ASSESSOR'S TAX/PARCEL#
6 , 914- z t c 4 G t - 0 0 4 0
TYPE OF PERMIT ❑ BUILDING 0 PLUMBING 0 MECHANICAL 0 DEMOLITION 0 ENGINEERING .11 FIRE PREVENTION
NAME OF PROJECT ? M 11J e i...‘Ce ilg14f%Tk+ PLAN) O CES
PROJECT DESCRIPTION kpo it a.,.. - S1'R lr,-L-5 l�' 0`' 1 L)ALLS 4
Detailed description of work to C.,.�ti..-t
be included on this permit only
NAME ..__... _ _ - __. -. ... ._ ~PRIMARY PHONE
PROPERTY OWNER )nil Ve14ToLES- -e.0�e4.... k `L-C
MAILING ADDRESS E-MAIL
(i L'4 d l(ole 1-1G .tt I,t`30
CITY STATE ZIP
r
NAME
PHONE _ u
Revue.. `--T-caxsTl tl--i Z`53-- t'7 a-Z 2-V7-
MAILING
- 7-
MAILING ADDRESS E-MAIL
CONTRACTOR 18S-5.- S 2-c( 1"- S'[' A,S21R�-er e A. d,Ij,1t.c7l-jSrEar-iyw-1
CITY STATE ZIP FAX `'''
e JT WA- (ieo A 2- Z-53--01z- 17-'1/
WA STATE CONTRACTOR'S LICENSE# EXPIRATION DATE FEDERAL WAY BUSINESS LICENSE#
ia,P.CVt-G1 tZ- / 3t / i 5
NAMEPRIMARY PHONE
c)c(TC se Ige-el- Zs-3-Eli z-- i zo-Z-
APPLICANT MAILING ADDRESS
E-MAIL
1 $s`S .$ 4&,)14.. ' ST - Ig.Tiiz,r a c , at„.-‘QTc-
CITY STATE ZIP FAX 1
Kz�T Cf1- x•'..31- 753--a-7Z- 7 Z-71 ^
NAME - _-_ _ PRIMARY PHONE C
PROJECT CONTACT 5i&-r✓ e-
(The individual to receive and MAILING ADDRESS E-MAIL
respond to all correspondence
concerning this application) CITY STATE ZIP FAX
-
NAME .- . . .
PROJECT FINANCING 14/i4.. 0 OWNER-FINANCED
Required value of$5,000 or more MAILING ADDRESS,CITY,STATE,ZIP PHONE
(RCW 19.27.095)
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 city as a pa • s a••lication.
SIGNATURE: s.' DATE 1 - Z 4- I-S
.--_________:PRINT NAME: - f:CT Se t P,es-ru—
Bulletin#100-January 1,2013 Page 1 of 3 k:\Handouts\Permit Applica