13-100476 . i
PERMITWIT, N
_art-of P hV.,A,
Federal Way /!� JAN 3 0 2013
PERMIT NUMBER ( / _ / v 4 �� _
TARGET DATE CITY OF FEDERAL WAY
_ CDS
' SITE ADDRESS SUITE/UNIT#
= 4-- o ") q V5- • \1 ' <(X�
PROJECT VALUATION ZONING ASSESSOR'S TAX/PARCEL#
TYPE OF PERMIT ❑" BUILDING ❑ PLUMBING ❑ MECHANICAL ❑ DEMOLITION ❑ ENGINEERING FIRE PREVENTION
NAME OF PROJECT \ i _ 5k AA ')G• \i\i - Di ' �tJ C /tip • L.C��I^�Y
i
PROJECT DESCRIPTION kat ft�A�i i
Detailed description of work to \\�`� �� W ( ,/� h/l
be included on this permit only LJ
NAME ^ \ -- �_ PRIMARY PHONE
PROPERTY OWNER �{ ?II14..\ I.
MAILING ADDRESS rr � ..FF. E-MAIL
1 -v 0 1 -Y�UA..set+C� ,Qi,ii \L-t,UO
CITY - `SA:f. ZIP
NAME � ��^� p/ ro I PHONE I
jl V�Lit/VV�1�/� �, �/�l�/t JCS-(J) ,-,fit L 'L�'l ,l'
MAILING ADDRESS / E-MAIL
CONTRACTOR q\ 1�� r'\v�-` /// -� ' /,1li�l ��til f,'1�.'V�1
CITY V Q%1/v\[ UIL, ' AIA STATE ZIP 1 ' J t F� l 'l•
v� ` Gw v`
WA-ET4ATECONTRAACTOR''SS'LICENSE* EXPIRATION DATE FEDERAL WAY BUSINESS LICENSE it
NAME -x t P�ARY PHONE
y....,
L Lon
APPLICANT MAILING DRESS E- L
CITY STATE ZIP FAX G` a(ti l y N1,��/•1:0'.'
e►A'k -;.�.� VJA Cl,%I ;L/ Y`vv- J
NAME / PRIMARY PHONE
PROJECT CONTACT -44A i V‘ • -).SIA'A
(The individual to receive and MAILING ADD s6kA E-MAIL
respond to all correspondence 0\ G""
concerning this application) CITY STATE ZIP FAX
NAME
PROJECT FINANCING ❑ 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 Iocal, 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.
YCV.001 -\•,)\504... ` . , ‘ 27�SIGNATURE: DATE
PRINT NAME: y I/Yl (/ r
Bulletin#100-January 1,2013 Page 1 of 3 k:\Handouts\Permit Application