15-103739 PERMIT • LATIS1
Federal Way RECEIVED
PERMIT NUMBER I _ { O - ✓ 9 _ •
'JUL' 3 0 2015
TARGET DATECIN OF FEDERAL WAY
SITE ADDRESS SUI UNIT#
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PROJECT VALUATIO ZONING ASSESSOR'S TAX/PARCEL#
$ ifI00 • � _a 1 30 - n Vin►
TYPE OF PERMIT ❑ BUILDING ❑ PLUIVING E MECHANICAL ❑ DEMOLITION 0 ENGINEERING Ik FIRE PREVENTION
ple.4't 9 q1-�
NAME OF PROJECT Ft �� r a` y (A C
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PROJECT DESCRIPTION &v.\
Detailed description of work to 1
be included on this permit only
NAME`. ,k PRIMARY PHONE
PROPERTY OWNER ZS O C)\ _� C (IL\ -G 2_ l�
MAILING ADDRESS (---r' E-MAIL
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CZY STATE ZIP �--
PHONE
NAME£LQ \ Tom- 1 n cy l OL/, 1.-4 VQ:CD- L-{c 1- q C 3
MAILING ADDRESS ) E-MAIL
CONTRACTOR p 0 03 c %'
CITY STATE ZIP FAX
C,r ( vA Pc, c)<I0 6'
WA STATE CONTRACTOR'S LICENSE# EXPIRATION DATE FEDERAL WAY BUSINESS LICENSE#
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_
NAME PRIMARY PHONE
l-31/(
MAILING ADDRRESSc�, E-MAIL {_ '
APPLICANT P� �`,cv) .1 3 1 (-1t10; a Ii �fn~ ( Q �
,CL,, I
CITY STATE ZIP FAX
Yv\ ,t1 P-h'cn 2
NAME a 11 PRIMARY PHONE
PROJECT CONTACT ` e -� �+ .t , �.✓11 l'
(The individual to receive and MAILING ADDRESS E-MAIL
respond to all correspondence
concerning this application) CITY STATE ZIP FAX
NAME
PROJECT FINANCING 0 OWNER-FINANCED
Required value of$5,000 or more MAILING ADDRESS,CITY,STATE,ZIP PHONE
(RCW 19.27095)
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 Iaws.
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 - '' as a • • t ' application. J o
•
SIGNATURE: DATE 7/ g !��j i
C_1'1 1
PRINT NAME: l �V i