15-103474 QECEIVED
CITY OF JULPERMIT A LIGATION
Federal Way 16 2015
CITY OF FEDERAL WAY
PERMIT NUMBER 1 6 _ t 0 qS� C/ _ r.- {, r) \ t\---
TARGET DATE
SITE ADDRESS SUITE/UNIT#
-33q3ii 8•14-1N4 saj-r ,S til 0
PROJECT VALUATION ZONING ASSESSOR'S TAX/PARCEL#
$ 60 9 t/ 3 0 - 0 0 O o
TYPE OF PERMIT ❑ BUILDING ❑ PLUMBING ❑ MECHANICAL 0 DEMOLITION 0 ENGINEERING Ill FIRE PREVENTION
NAME OF PROJECT f/UfL/7'/AjAT/D/'i/4C
PROJECT DESCRIPTION � ,.r�
Detailed description of work to Jl<fcn,L/I,V 7/t r/j7b0.57-/e& sP/viVL./sGa st6jl v•aI
70 4eeo Ie,1 Tt
be included on this permit only 7h ett/ Legal )91004A15
NAME PRIMARY PHONE
PROPERTY OWNER g t f'14 ac %404-C4,:gtl
MAILING ADDRESS E-MAIL
/1/00 NZ Sr 5TE.38o
CITY STATE ZIP
13eatdOE WA
NAMES�/Tfi FuZ S//rtf,,5 PHONE -�e lr
MAILING ADDRESS E-MAILd/ nt
CONTRACTOR //al'c1114 4I/ZC t isrs,A,tt-Q 444iit,G,a0»
CITY STATE ZIP FAX
Mare - `d" to - 111 -
WA STATE CONTRACTOR'S LICENSE# EXPIRATION DATE FEDERAL WAY BUSINESS LICENSE#
SP1,T N f.S I36,oT / /f-1- mpg's-tai•ge_
g I NAME /1 / /te7 PRIMARY PHONE
,5rh,Z'11 ftIZ4 SYSTEiiS X3- a4-96?8'
MAILING ADDRESS E-MAIL
1,/}D(� c1/`' /WEE 1eAin ti
APPLICANT 4.,e��
.
STATE
CITY 4 WA ZIP/82/071/
82/071/ Fa'S - VT Lur
NAME,- PRIMARY PHONE +�
PROJECT CONTACT J t.F S{i r i t t o2c - -pU' '
(The individual to recewe and MAILING ADDRESS
E-MAL /'i �j ,�.�
respond to all correspondence f10<7 ' AWE fC ry,fi �,� Tir(.L3�?1
concerning this application) CITY STATE ZIP FAX
it all A o_ift 1P'a.25s-- Te14,-12.l6
NAME
PROJECT FINANCING 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 to the city as a part of this application.
'
SIGNATURE: i t///t. i DATE Pg/S---
PRINT NAME: JGPrRE'/ i
Bulletin#100—January 1,2013 Page 1 of 3 k:\Handouts\Permit Application