15-105145 OF A • PERMII•APPLICATION
Federal Way RECEIVED
'' OCT 0 8 2015
PERMIT NUMBER I _ 1 O C 1 451 FP
- TARGET DATE CITY OF FEDERAL WAY
SITE ADDRESS // /� / /�
3/, -7 pc/ `- /O 4 (?)(Ch b IQ (f !1/ '�,�- 57, SUITE/UNIT#
PROJECT VALUATION ZONING ASSESSOR'S TAX/PARCEL#
$ �4 k5'` o° D -L- / D q - �I ( Z
TYPE OF PERMIT 0 BUILDING 0 PLUMBING ❑MECHANICAL 0 DEMOLITION 0 ENGINEERING,'FIRE PREVENTION
NAME OF PROJECT /1-1/4/12;(fr,Vt Oji /
PROJECT DESCRIPTION /
Detailed description of work to ,P-,•2 7161-
3 /( J /LIi/ T L 67
.z.4 1/3
be included on this permit only
NAME /�/ -.- PRIMARY PHONE
PROPERTY OWNER /�,/4�? 296 3 q - -??I
0/ MAILINGS , 4 n/ E-MAIL
Zc•• '12-..&' Cnr .., v" (2y
STATA P b,
NAmE I 3P('461b11 -P 1111-i° 551- rdX 5 -
P77 -i y 3 f‘?41'
MAILING ADDRESS
"f"--
CONTRACTOR
� 1 Jh ,r� S E-MAIL
CONTRACTOR h f ��`"�� 7
C ; 140 ST# ZIp��O�/ FAIT ,,, �,_‘ 7
yy3 1,TE CONNTC�OR' ICEI/2 .7 -j/ EXPIRATION j FEDERAL`� WAYIBUSINESS LICENSE#
NAME t - 1.-
_. .- ...._._____...
/ S/T 9-(�-19 0 9 a s---3. /Cs--0 9 PRIMARY PHONEn
APPLICANT MAILING ASD 3`f y� 671 /t Se (MAH. /'�+,(�,�� �f}I _ n /'
CITY�O�"li/�1 ,,./(,:,
,.(/�.
ATE.
._. ZL `� D F� �%l�( I 'I cC 0JGT 1(�-%
NAME ( PRIMARY PHONE
PROJECT CONTACT e G5 4-4 n l D
(The individual to receive and MAILING ADDRESS E-MAIL
respond to all correspondence 5 `'Q l.¢�S ': '(�C
concerning this application) CITY STATE ZIP FAX
PROJECT FINANCING NAME 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 def • • such claim),which may •e made by any person,including the undersigned,and filed against the city,
but only where such c •im a --es out of the relia , of the city, including its officers and employees, upon the accuracy of the
information supplied o the ci•, as a •rt of this ap; cation.
SIGNATURE: __l/ DATE
PRINT NAME: ' /-e/of S*,,g'iz(/d
Bulletin#100—January 1,2013 Page 1 of 3 k:\Handouts\Permit Application