15-106440 PERMI1APPLICATION
Federal Way RECEIVED a71
19
_ � b + � q _ F DEC 21 2015
PERMIT NUMBER 1 "I , - -
J CITY CriPt WAY
CDS
SITE ADDRESS SUITE/UNIT#
y �� 15� ue 5 F c�, l ) \ J4 9qc�
PROJECT VALUATION ZONING ASSESSOR'S AX/PARCEL#
TYPE OF PERMIT ❑'1++BUILDING ❑ PLUMBING ❑l MECHANICAL ❑ DEMOLITION ❑ ENGINEERING , 1.FIRE PREVENTION ,
NAME OF PROJECT CL.1 t \e_f• C E Mei 1 _ r� -.\,-)m( �i E- Atax.M lJ. .��t'1.,t
PROJECT DESCRIPTION I N�-ail( N I re c.J.. r . � -P M 11 n t,.,) .f L1AC
Detailed description of work to
be included on this permit only
N E F--Lbdket\lkoLf)
;'^,,�, PRIMARY PHONE
PROPERTY OWNER MAILING ADDRES MAIL
w .4 154 A ie . . liN'I4-tic -C\A pc. 0(3
STATE ZI
P e('c�,� Wc� WA 4civ3
AM r r Q p I-i\c L.-14\C_
_I, p' [Xa,'y1 ,e�
NAME �� ��C.-' t`J `�_V`� PHONE��7� - �V \' 37 lJ 1
LINF,AADDRESS E-MAIL
CONTRACTOR rQ '^Oxy'1�3\ / /} 1-1'
CITY P� a. STAT�k ZI>'` �7 FAX
- V�-J/ ' l
t, • W (DIY
WA S'irATE TRA IOR �I./I�C _ # EXPIRATION DATE R FEDERALWAY BUSI3SSLI LICENSE#
NAME
au
j..�p �5 A' \/� PRIMARY PHONE
au �.C� //','ts
APPLICANT MAILING ADDRESS E-MAIL
CITY STATE ZIP FAX
NAME PRIMARY PHONE
PROJECT CONTACT 1,.,�nic�Se j �C.i`e 3 - i{- 37o 7
(The individual to receive and rING ADDRESS E-MAIL',- I I -
respond to all correspondence v � 73 i 7 Li�c.Se`{ {_0(,),.G,4- 5 5A -t51�^
concerning this application) C STATE z FAX l �/ u'
a_ C‘11:14) VA 1123 73 IS -Mq-37i Lt 1
NAME
PROJECT FINANCING ❑ OWNER-FINANCED
Required value of$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 supplie the city as a part o his application.
SIGNATURE: ' DATE /,)-1,9 J ' i S
PRINT NAME: Lin el, ni J c •S 117' /
Bulletin#100-October 26,2015 Page 1 of 3 k:\Handouts\Permit Application