17-103265lier... 2//7 2 -/- (
4 PERMIT APPL cATIQN
CITY Of �...✓
Federal� Y PERMIT CENTER+33325 8th Avenue South+ Fe e -6325
1 Way V 253-835-2607 + FAX 253-835-2609 +permitcenteiCn7cityoffederalway.com
JUL072017
PERMIT NUMBER 7--.. – t D 3 Z Co 5 _ FP CITY OF FEDERAL WAY
-- — TARGET DATE COMMUNITY DFVELOPMENT
SITE ADDRESS SUITE/UNIT ii
IOW J.28 6+• fe evaI i ON ZONING A R ,eta " �-ao►ez 142
PROJ$"1I6(01 . oc, O S 21 G L-/ - 9 O Os
TYPE OF PERMIT ❑ BUILDING D PLUMBING 0 MECHANICAL 0 DEMOLITION 0 ENGINEERING WIRE PREVENTION
NAME OF PROJECT '?J Qw J 1-1 li
v 1 3 J� im f le e nt i
m (�L Kj
PROJECT DESCRIPTION
t POYfaibleS I-F2 dTh c 20) de vCe&
Detailed description o work to 'I (� ,( (_ •
be included on this permit only
NAME PRIMARY PHONE
PROPERTY OWNERicf?
MAILINGr�i w Thh\t c S hco SS E-MAIL
/ S. 21VSSS.
CITY , STATE
a�U. A L A '�t �.- ,-R
PHONE
Verdian �.. vritt- >v tem ., .. -1022- ys
CONTRACTOR ' " ) l 'Y J EMAILSIT
e I WSTATE
ZIP_
`813 1 FAX
WA STATE ONT CTOR'S LICE_NS N EXPIRATION DATE FEDERAL WAY BUSINESS LICENSE#
( ( , sz3 _ "II0
ANTEr., PRIMARY PHONE
(0001,1 (ierOtbCk—
APPLICANT MAILING ADDRESS E-MAIL
C r STATE ZIP FAX
I /: Al� , LA i ,W rte
NAME s41 �_ ` �^ T PRIMARY PHONE
t' l 1
PROJECT CONTACT Y II"1b -
(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
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 • ---owner's responsibility for compliance with local, state, or federal laws regulating
construction or environmental laws.
I further agree to hold harmless the ••ty of Federal W. as to any claim(including costs, expenses, and attorneys'fees incurred in
the investigation and defense of suc cl•im), which • •e made by any person, including the undersigned,and filed against the city,
but only where such cl•' arise out o ra g of the city, including its officers and employees, upon the accuracy of the
information supplied t• th city •,- a p. cation.
/
SIGNATURE: OP:0DATE -7' 5 - I —PRINT NAMEOU1y
//1 e9 Ai, 0
Bulletin#100—January 29,2016 Page 1 of 2 k:\Handouts\Permit Application