12-102343 RECEIVED _ ! 0
CITY OF
a\ 2 5 ZPERM _3 4
IT S MF CO ME PL DE EN
Federal Way
COMMUNITY DEVELOPMENT. S OF FEDEAPPLI CATION
253-835-2607•FAX 253-835'16M 'J�J
u wu,.ci(uollederaLwuU.mm �'� g:rr1/'+ M ri -tri� 1/� -1
SITE ADDRESS SUITE/UNIT#
356, v o .
PROJECT VALUATION ZONING ASSESSOR'S TAX/PARCEL#
s sal 000
_ _
•
TYPE OF PERMIT ❑BUILDING ❑ PLUMBING 1=1MECHANICAL
❑ DEMOLITION ❑ ENGINEERING TiNFIRE PREVENTION
NAME OF PROJECT
(Tenant Name/1tomeou ner Last Nanie) C C�A ` �j \ r\/ UA\ 1
PROJECT DESCRIPTION F '
Detailed description of work to Y..��C �/�- I1��`o
F. ^
t 1
be included on this permit only „,:pot E (Y1 •
NAME - PRIMARY PHONE
PROPERTY OWNER C �if1(\ L Pg0v E—
MAILING ADDRESS E-MAIL
CITY STATE ZIP
(v‘ a 6121.0 3 3oo
0r R
PNC_ w ZIP ua u FZ53 c2C.330 Ce C., if."'
WA STATE CONTRACTOR'S LICENSE# EXPIRATION DATE FEDERAL WAY
pp LA.2CL
PROMs ip24p2 0.
APPLICANT MAILING ADDRESS E-MAIL
CITY STATE ZIP FAX
PROJECT CONTACT NAME PHONE
(The individual to receive and
respond to all correspondence MAILING ADDRESS E-MAIL
concerning this application)
CITY STATE ZIP FAX
ALTERNATE CONTACT NAME: PHONE E-MAIL.
PROJECT FINANCING NAME ❑
OWNER-FINANCED
Required value of$5.000 or more
IRCW 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 to the city as a part of this application.p #
SIGNATURE: v� DATE 0 `
C) p�"L,/
PRINT NAME: 1Q.1 1�1 t[ . l'Cx�
Bulletin#100-January 1,2011 Page 1 of 3 k:AHandouts\Permit Application