13-104733 ( 3, _ o 7- 33
CITY OF PERMIT
Federal Way Rt
I'A
COMUNTPDEVEIAPMENTSERVICES APPIICATION E E FP
253-835-2607•FAX 253-835-2609
www.cityoffedera(wau.com OCT 2 4 2013
SITE ADDRESS CITY OFF p-I;, lIT'#AY
3344341 $4" Igoe S, 103 +d 2o(a
PROJECT VALUATION ZONING ASSESSOR'S TAX/PARCEL#
$
11,000. Co 0 R y 3 0 - 0 0 0 0
TYPE OF PERMIT 0 BUILDING 0 PLUMBING 0 MECHANICAL
0 DEMOLITION 0 ENGINEERING t 4IRE PREVENTION
NAME OF PROJECT
(Tenant Name/Homeowner Last Name) K lam(„ W f LL/A Err)(....T`71
PROJECT DESCRIPTION I tJ TW LL &I CW Pc .j DEticr" %r &i�KC-E1Z 6A.lc--c.J
Detailed description of work to ACT GC/C/AI Gi •
be included on this permit only
NAME PRIMARY PHONE
PROPERTY OWNER
q I1 AUEKIUE PAUIL.I O LA
MAILING ADDRESS E-MAIL
3343.4 $ 4' +9✓C tf
CITY STATE ZIP
t NT L.J4 9Q,003
NAME PHONE
11(2..c N E IZ, C r 45 T CZ.t C../11 0^4 . tut. . 233. 812 .1221-
MAILING ADDRESS E-MAIL ?Pei-Ca AD a
CONTRACTOR 1655 55 J. 206+4 41 ARtHfcil.0 pP.ISTR•.1Uri 00,Com
CITY STATE ZIP FAX
KtitT WA 95032 253• -in
WA STATE CONTRACTOR'S LICENSE# EXPIRATION DATE FEDERAL WAY BUSINESS LICENSE#
C.44 ET Ll 9 D il: Oq / I //4.(
NAME PHONE
?e-r DCt._c, wDc 233•g,'12•'1221
APPLICANT MAILING ADDRESS E-MAIL
CITY STATE ZIP FAX
PROJECT CONTACT NAME PHONE
(The individual to receive and 'Peers` p E i.,fa A O a
respond to all correspondence MAILING ADDRESS E-MAIL
concerning this application)
CITY STATE ZIP FAX
ALTERNATE CONTACT NAME: PHONE EMAIL
PROJECT FINANCING NAME o OWNER-FINANCED
Required value of$5,000 or more
(RCW 19.27.095) MAILING ADDRESS,CITY,STATE,ZIP PHONE
I certify under penalty of perjury that I am the property owner or authorised 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 •art of his application. /
SIGNATURE: DATE /)/� ( / (.3
PRINT NAME: /kW Vel-e-fL fid.,Ltv-A.0
W
Bulletin#100—April 14,2010 Page 1 of 3 k:\Handouts\Permit Application