16-100897 A
` CITY OF _ PERMIT PPLICATION
Federal Way ti?ERECEIVED
PERMIT NUMBER 1 (0 _ I C 6 9 T -F`� FEB 18 2016
TARGET DATE
CITY OFFEDERAL WAY
SITE ADDRESS SUITE/DMT#
vS. 13c2t•-10 i 1D '`-PctL 7 ,S)6 itt k
PROJECT VALUATION ZONING ASSESSOR'S TAX/PARCEL#
$ -S; CIC C0 _* Cly IVID Aral - )-
l
TYPE OF PERMIT ❑ BUILDING ❑ PLUMBING ❑ MECHANICAL ❑ DEMOLITION ❑ ENGINEERING-I ''FIRE PREVENTION
NAME OF PROJECT 5?-And (s ec---1pc '151 o I ric- i
S. 3s2l�f> E�e.t-cm?�Ufp5-6-111a-
PROJECT �'
DESCRIPTION i
Detailed description of work to ( i�(u Zhn�'-)
be included on this permit only ,k \e ( .\/r J only ,---, ., J , �C, 1_}'?j)4l 4.)WK)4,_
NAME _ PRIMARY PHONE
PROPERTY OWNER 1 1 C' J`c T 'C `� ,2. 3 - ,53;_- 211--7/
MAILING ADDRESS '7 �./ E-MAIL
3 S.,-.),. Hi :mac' ,.ou i r,
CITY A STATE ZIP
FC.C42e,Tet, `'I V,V)I - 7k7c
NAME PHONE
kl
MAILING ADDRESS E-MAIL
CONTRACTOR i2' '*X 6 "1 1
CITY ; 1—� STATE ZIP FAX
t L.;'i - 7 'FS' 1E S
WA STATE CONTRACTO 'S LICENSE# EXPIRATION DATE FEDERAL WAY BUSINESS LICENSE S
3 I1&g / i.4-1boy-L5
NAME PRIMARY PHONE
h\' 'E rJ ( a YLI f 2f -
APPLICANT MAILING ADDRESS l -M
EAIL
3342 ) ‹1 � ;Y k
CITY STATE ZIP FAX
. r -, c.--7 - 7R1)a3_
NAME _�_��� PRIMARY PHONE
____
PROJECT CONTACT �C7YYlt C%J \j( 1---
(The individual to receive and MAILING ADDRESS E-MAIL
respond to all correspondence
concerning this application) CITY STATE ZIP FAX
NAME
PROJECT FINANCING ❑ OWNER-FINANCED
When value is$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.
nd
SIGNATURE: � tcDATE 2--�1 S
i b
PRINT NAME: N°b,I / CH-AY J
Bulletin#100-January 4.2016 Pace 1 of 3 k:\Handouts\Permit Application