17-103686 .,. PERMIT APPLICATION
Federal
or PERMIT CENTER+33325 8,h Avenue South+ EGta ivvIt E�-6325
253-835-2607+FAX 253-835-2609+ oci..,mantcritcay,olfccirra,wn} •Nm
� (e � 62AUG 01 2011
( 7 )PERMIT NUMBER F F CITY OF FEDERAL WAY N,.
_ _ - - _ _ TARGET DATE COMMUNITY DFVEI '
SITE ADDRESS SUITE/UNIT#
�SPROJECT IONE8
8(QW e"'/ e-rk ,e ec 647'BTAX/PARCEL
$ 5,voo 02 1 C ,l- Co l„ - O p -3 o
TYPE OF PERMIT ❑ BUILDING ❑ PLUMBING ❑ MECHANICAL 0 DEMOLITION 0 ENGINEERING IRE PREVENTION
NAME OF PROJECT /�/� ���� 4 n c7 S -1-
,
PROJECT DESCRIPTION vi sir,,, . BA ce 1,t,. {-o C u A r, 4c.: it.e_.,--..) "- --\,
Detailed description of work to E k.S V M 7 1 A 5-0.ice, +o C c- .w ,, .
be included on this permit only
-
NAME( 7 .2UL PRIMARY PHONE
PROPERTY OWNER
AA.‘S gem<<o,Q t'�2.� (o �,rs-- D 5 v(o
MAULING ADDRESS E-MAIL
_(p?a25- 11 16,411 4 . MC b,, }t ‘,vv (.Iivr.5,4-ccnerhJ i<,c
CITY STATE ZIP
rf avtlan► 1AJA '?8O33
NAME PHONE
O l 5 e r, 1-e-c.-irt-I c 53-01,2-C tV.-
MAILING ADDRESS ,�.1 E-MAIL
CONTRACTOR 3.42 S W wS h M`�C/i'1 -k' 1 v.)1-+Yt y eo(.yen Uirc441 (4.441--
CITY
+d J
CITY t STATE ZIP cJ FAX {
Van E INA- , too
WA STATE CONTRACTOR'S LICENSE# EXPIRATION DATE FEDERAL WAY BUSINESS LICENSE#
i.toEA.)=t,`/-ate / /
NAME PRIMARY PHONE
`7 C.0'191--•C- 41 S C - --0.L- --CLT
APPLICANT MAILING ADDRESS E-MAIL
CITY STATE ZIP FAX
NAME PRIMARY PHONE
PROJECT CONTACT P1-4- ce 5 CLitl}i�L c
(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.
SIGNATURE: "...6•,../ DATE '-3l///PRINT NAM : CU✓112-ce j
Bulletin#100—January 29,2016 ( Page 1 of 2 k:\Handouts\Permit Application