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CITY OF 49. PERMIT
Federal Way n cE jk/ ME PL DE ECOMMUNITYDEVELOPMENT SERVICESL.�
253-835-2607•FAX 253-835-2609
uuAl,ciluoffederaIlcau.rom
JAN 1 1 2012.
SITE ADDRESS
-�h CITY OF �E�ERA . V`VA` SIT
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PROJECT VALUATION ZONING ASSESSOR'S TAX/PARCEL#
TYPE OF PERMIT ❑BUILDING ❑ PLUMBING 0 MECHANICAL
0 DEMOLITION 0 ENGINEERING pl"RIRE PREVENTION
NAME OF PROJECT �.
(Tenant Name/Homeowner Last Name) \ ' \ \t)y. A Me. \c `ne
PROJECT DESCRIPTIONq
Detailed description of work to ' C1-3c 1�\ -\-� `r Nne
be included on this permit only •
\�/`_\ c1,2_>
2A.,.f., \-e.�- vyft,A
NAME (� ,.�1 _ ^� PRIMARY PHONE
PROPERTY OWNER (1\(N\� '` \ V \lJ�` \ �`)..JCj 2'-.723 '\L\Z-7
MAILING ADDRESS E-MAIL
CITY STATE ZIP
NAME Lon `.\\rte :-\eL \or\ 254S* Z-
rikeING '°J p-MAIL ^
CONTRACTOR �/I��Y/�\ J1— //-'/ \? \,� �A F�ry42{2_444s),.)
'S(,n�� (�, C.T4D1.)•j ^1f,
l I \\�\ \ e� STATE I yam. ZIP 6‘w....... G....'7�V ). /l c [� `Y.
y� STATERACTOR i ��'s RPIRA N \E 2. F !' L' io 5/d o/LICENSE
le - I!l..
NAME PHONE
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APPLICANT MAILING ADDRESS E-MAIL
CITY STATE ZIP FAX
PROJECT CONTACT NAME\`J\ee, \CI(i ‘ le)
42644700
(The individual to receive and PHONE
respond to all correspondence MAILING ADDRESS y E-MAIL
conceming this application) \�\\ . NCCISC C:CCI y3y``1 Q O
CITY STATE ZIP
'(\AA\ ate'eX-. CAS+Cs?_ 442-54461-S C
ALTERNATE CONTACT NAME: PHONE E-MAIL
PROJECT FINANCING NAME
0 OWNER-FINANCED
Required value of$5,000 or more
(RCW 19.27.095) MAILING ADDRESS,CITY,STATE,ZIP PHONE
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 o the city as/apart of this application. /
SIGNATURE: ��/J�. R4Liviet_d_____DATE / z 1}2,--
PRINT NAME: (7:::::::,:t6-- i(b ,13061/750n
Bulletin#100—January 1,2011 Page 1 of 3 k:\Handouts\Permit Application