16-100427 •ECEIVED PERMISAPPLICATION
Federal Way JAN 27 2016
arY OF FEDERAL !WAY N PERMIT NUMBER _ 0 D _ iPr
TARGET DATE
SITE ADDRESS SUITE/UNIT#
;SOS 33 St fPd'eraI w ', VW; elt'0o3
PROJECT VALUATION ZONING ASSESSOR'S TAX/PARCEL#
$ 1 LI 9 2 Lo 4 O _ 0 2 1-
TYPE
TYPE OF PERMIT ❑ BUILDING 0 PLUMBING 0 MECHANICAL 0 DEMOLITION 0 ENGINEERING x IRE PREVENTION
NAME OF PROJECT /\4S
Add / (2oe(ocaM (2Z0 ) S pr rt k(er hrok nrw UTQ II ave
PROJECT DESCRIPTION
Detailed description of work to O(.6*ce 1 p
okyouk tee r coverFee- ( ! 13.
be included on this permit only 1
NAME PRIMARY PHONE
f SF fro(rr C)rf
PROPERTY OWNER MAILING ADDRESSS DC S `A C r E-MAIL
czTYIJILr �t lYw A -L STAZI lig
NAME ��C o PHONE
Fire /"(v 1 1/Z',, 2,00-(442• 3(00
MAILING ADDRESS ,I3^ S` I � C.r E-MAIL
CONTRACTOR /U�' �f \ / a ) [� (�
CITY¶Jkw �°A ZIP 1�1 if 70 FAX
� -1. ... 33S-to 3fi-to
WA STATE CONTRACTOR'S LICENSE# EXPIRATION DATE FEDERAL WAY BUSINESS LICENSE#
co co pti�N�� 1 / )3 /2013 Zo-ut"Initraci . oo Ii,
NAMEPRIMARY PHONE
Deario b,..61 re
2047-(43 33q4-1
APPLICANT MAILING ADDRESS E-MAIL
1•10c IS) .Cf — dbi'ar'e eCOL C-4. 're.
CITY STATE ZIP FAX
-jV wi (0) VNIA— gg(t,c
NAME9..0(0-(6 ?- 353'1 PRIMARY PHONE
PROJECT CONTACT fkan`D �i are
(The individual to receive and
MAILING ADDRESS E-MAILt
respond to all correspondence / !N 1 db ave @ (AS Co•F iC corn
concerning this application) CITY STATEZIP 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 authorised 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: v, DATE 1/2;S-/24
it(0
PRINT NAME: p(/' 1 1 1-.31
Bulletin#100—December 29,2015 Page 1 of 3 k:\Handouts\Permit Application