15-103476 A
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CITY OF `�-r JUL 16 2015 PERMIT APPLICATION
Federal Way
CITY OF FEDECDS RAL WAYFIRE
PERMIT NUMBER - '1 f, °-'' ? 1 _ - Y' J/
lll_Q_ ✓✓✓ �G 1 _I_ TARGET DATE
SITE ADDRESS SUITE/UNIT#
33451-i r'` /WES- 0.73
PROJECT VALUATION ZONING ASSESSOR'S TAX/PARCEL#
$ .2Si3 ( J q 11 3 o - O '' O O
TYPE OF PERMIT ❑ BUILDING ❑ PLUMBING ❑ MECHANICAL ❑ DEMOLITION ❑ ENGINEERING IFQ FIRE PREVENTION
NAME OF PROJECT til-1,--4 WiWl ?115 Okipt3415 IJvU'Ti
PROJECT DESCRIPTION �i��-
Detailed description of work to NOLViV' J1E `/cT/4f'6' SPI2/i11&S:.l(. 5 Z44 70 e0/1/10j1 A t
be included on this permit only 11Vk) ifillZ15 YL`, "/L//lieS
NAME s a PRIMARY PHONE
T
PROPERTY OWNER ' ' <l^� q
MAILING ADDRESS V"1' "�
1/00 AIL re-
r 3138b
CITY GG ' / STATE ZIP
us
Luzi: /AA
NAME 5Mi7� f J /�T��J PHONE yeve:-. DsT
MAILING ADDRESS E-MAIL �" /l/
CONTRACTOR //al,cL//�1 4 l t �'"�'"'°l�& ? h'�Ji/L' Fr
CITY I STATE ZIP FAX
WA STATE CONTRACTOR'S LICENSE# EXPIRATION DATE FEDERAL WAY BUSINESS LICENSE#
Swi IT 1l/.3/3(.Jfi 42 / 3/ //( I - - s-00-13e_ 1
NAME PRIMARY PHONE I
301 11-14 fazig SY5T A 15 X3- Wig-94 7e
APPLICANT MAILING ADDRESS E-MAIL
CITY STATE ZIP FAX
146004 W4 /Me/ 05-3-.'51$` x:11
NAME,,,,,,.y ��„ PRIMARY PHONE
PROJECT CONTACT _I Z. ,,i'1(lir - - � #'
(The individual to receive and MAILING ADDRESS��D�,y .�t EMA L
respond to all correspondence f' <7 4V� ✓C � S«*i$ life.Galli .
concerning this application) CITY STATE ZIP FAX
1 ' e`/ 4-1 .25,3- qt, .1244'7
NAME
PROJECT FINANCING 0 OWNER-FINANCED s
Required value of$5,000 or more MAILING ADDRESS,CITY,STATE,ZIP PHONE
(RCW 19.27.095) .
I
i
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 i
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 I
information supplied to thethfcity as a part of this application. J,/
SIGNATURE: a�� " /L DATE "7"//V/6--
I/ /6--
PRINT NAME: �FF2E.yl ma
1
Bulletin#100—January 1,2013 Page 1 of 3 k:\Handouts\Permit Application 4?'
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