15-100578 4111
PERMIT APPLION
Federal Way
/tom 0 FEB 05 2015
PERMIT NUMBER �J _ TARGET DATE CITY OF FEDERAL WAY
CDS
SITE ADDRESS SUITE/UNIT#
33 4-oS ,4✓- 5. So 1..791
PROJECT VALUATION ZONING ASSESSOR'S TAX/PARCEL#
$ 8890 1 2 6 5 U _ o o
TYPE OF PERMIT 0 BUILDING 0 PLUMBING 0 MECHANICAL 0 DEMOLITION 0 ENGINEERING X FIRE PREVENTION
NAME OF PROJECT 14-19y i5kVe4- .k ��//I<lb n+ Cel
43/0 Rpal re1OCR1e. p - )424 -
PROJECT DESCRIPTION
Detailed description of work to 4/&11 4,01 G/O//L d✓\ 36' fen ti k wS
be included on this permit only
NAME / PRIMARY PHONE
L�
PROPERTY OWNER /, Potti'17 1/ f I 2 2,04t(2-11AD4 81 t(2- �
6<9OMAILINGAD � .SteUY1tv5 y Ave ye 3025 E-MAIL L �ArL �iLbafeaC2Y4',.1
CITY STATE ZIP
gate wf¢ 9dlol
NAME PHONE /
Srn1.'L1 F►�L SYf�e" s 2-53 R 6
MAILING ADDRESS E-MAIL
CONTRACTOR 110 AweSY'f'i ✓e e 'Fwlfieo6.o.fjces„+I'VAFi're.(0M1
CITY ACO STA]'F� ZI 6$'2, - FAX 2.5 (O-(Z-r r0
WA STATE CONTRACTOR'S LICENSE# /rEXPIRATION DATE FEDERAL WAY BUSINESS LICENSE#
SMTTMF5I3‘O16 /1-87-e000S5.#0, ./31..
NAMEJohY' g lkt. -4,,,,J C,4 $r,1•iki 6, PRIMARY P2 US/
MAILING ADDRESS E-MAIL
APPLICANT )
CITY STATE ZIP FAX el&-/ZJ(,
Tel_Core. wR 91 l'Zy-
NAME PRIMARY PHONE
PROJECT CONTACT SaN'l Q 6JPi't•C4
(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 19.27.095)
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: DATE 2- Sr/S
PRINT NAME: J1,4" R 4I L q.
Bulletin#100—January 1,2013 Page 1 of 3 k:\I-Iandouts\Permit Application