15-103475 ', RECEIVED
Iti_ 16
2015 PERMI CATION
CITY OF CITY OF FEDERAL WAY
Federal Way
CDS
PERMIT NUMBER 1 — 1 j �I _ r
'Ar TARGET DATE
SITE ADDRESS SUITE/UNIT#
33113'4 Ave- s /04
PROJECT VALUATION ZONING ASSESSOR'S TAX/PARCEL#
$ 8 60 Cl 3 0 - 0 0 0 v
TYPE OF PERMIT ❑ BUILDING ❑ PLUMBING ❑ MECHANICAL ❑ DEMOLITION ❑ ENGINEERING ISI FIRE PREVENTION
NAME OF PROJECT p ip f fi f>/i(S/O�jriL 0/01Z74116-
PROJECT
/01Z,T4p6
PROJECT DESCRIPTION /��
Detailed description of work to /70/O/fK�E '/sT/�` 6 j?R/y(1& j�! TE/!7 7' i / 0))iT".
be included on this permit only / ,•lS 6-� �ye
GV G/
NAME PRIMARY PHONE
PROPERTY OWNER t ^ z/04/_6 ry�
MAILING ADDRESS E-MAIL v�
/M/Oa AZ sr .5I-313'0
CITY STATE ZIP
Ar
do
NAME 111/7 rl it 51/4/57-tpro PHONE -0'78" .4
MAILING ADDRESS E-MAIL,/��.�ys �r
CONTRACTOR //UP,L//4 /nvg g Je" '.e't� °7 TI°2.6,,,,7
CITY ( STATE ZIP FAX _
14epv►+q 11.c�14 - Klt, /216,
WA STATE CONTRACTOR'S LICENSE# EXPIRATION DATE FEDERAL WAY BUSINESS LICENSE#
Sol,TJ-1F5 f. 0T 42 / 3/ //<"" 1f-Ey- c000Ks-tai-
NAME PRIMARY PHONE ,
j111 I TV / Sys T S X3- 'g X' '
APPLICANT MAILING ADDRESS E-MAIL
CITY 1
��}}//0n STA,T^E ZIP /�J/ FAX M
NAME PRIMARY PHONE ,
PROJECT CONTACT J tFI 5 (Th' -t -X.° 2
(The individual to receive and MAILING ADDRESS
respond to all correspondence /1P0 41 `" 4l.5
/I fl s'�*� �'/�-G�
concerning this application) CITY STATE ZIP FAX i
'fir cwu1 f..:J ' tg/04/ 6253— l�r'/Z1(AP
NAME
PROJECT FINANCING 0 OWNER-FINANCED '
Required value of$5,000 or more MAILING ADDRESS,CITY,STATE,ZIP PHONE
(RCW 19 27.0951
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 I
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. t
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: (11/4"
'1/ �{f�I( DATE 7//43 t
(l s
PRINT NAME: E PP 5m in4 I
I
Bulletin#100—January 1,2013 Page 1 of 3 k:\Handouts\Permit Application i'`
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