17-103848 ,► RECEIVED PERMIT APPLICATION
CITY OF
FederFederal Way AUG 1 O 2017 PERMIT CENTER+33325 8th Avenue South+ Federal Way,WA 98003-6325
al 253-835-2607+ FAX 253-835-2609 +permitcenterrii;cih-offederalwav°.com
CITY OF FEDERAL WAY
_ nNTY ENT
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PERMIT NUMBER v _ 0 I
— TARGET DATE
SITE ADDRESS SUITE/UNIT#
Wi, SCD GAFF LoAy C. ►ii R.— —L
PROJECT VALUATION ZONING ASSESSOR'S TAX/PARCEL#
$
LPL i i (_z S 1 , cab Ha �. _- CD 9 ,,) ( c,,,, Li - 9 ? 0 8
TYPE OF PERMIT ❑ BUILDING 0 PLUMBING 0 MECHANICAL ❑ DEMOLITION ❑ ENGINEERING Dig FIRE PREVENTION
NAME OF PROJECT COW- ► Y Z b in c g 1 O 1
PROJECT DESCRIPTION
12�?L_PC Exis iTkic T��E A 1-A 21v1 SYS;I t"1
Detailed description of work to c_K- —1 S-1 b 2y I-R 01-FL...
be included on this permit only
NAME PRIMARY PHONE
374? FEDE(lPL i.0t1 (LA-1.4) O(ii,L)F(L 7,10 c y
PROPERTY OWNER MAILING ADDRESS E-MAIL
J LAS IF 1_,3 Au , �,u? aec
CITY STATE ZIP
L0 Scs ?1,ALIY\ . �AC4-) } L ?_S LkC 1
NAME PHONE
PACIFIC L1m 7f�� f'QCRGIy LLC. C95.- 7Q1'7 -C`-l70
MAILING ADDRESS E-MAIL
CONTRACTORt-rrt,R /aI y 133OC� o1fLL FUEReT1 H1,_1?/ ri)o._'triolpc4t ecorAcAsl./vC-7-
CITY STATE ZIP FAX
t Y ALL C4C;E.k. wiz) 129S0
WA STATE CONTRACTOR'S LICENSE# EXPIRATION DATE FEDERAL WAY BUSINESS LICENSE#
r�Acsv-LGo 9C'L4 t/ , / I cl
NAME PRIMARY PHONE
ROO rY\AYPftiac (ZS (ell
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MAILING ADDRESS
APPLICANT E-MAIL
?poi?) ZFIati. tlSo (Bc ItiEuk_, CtpC2t=zT i--}0y Px._a,�yx-cl6ccracAl.,�,ai
CITY STATE ZIP FAX
m1_1.-1_ Ce-E u=pr 7P0 i 2
NAME PRIMARY PHONE
PROJECT CONTACT FR n' A- A i'i L E L/-4 i_,y
(The individual to receive and MAILING ADDRESS E-MAIL
respond to all correspondence
concerning this application) CITY STATE ZIP FAX
NAME
PROJECT FINANCING rilOWNER-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 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: ;�(eI J �'� DATE C%I/L7 I/ -1
PRINT NAME: ' es L m A y 10 iL P
Bulletin#100—January 29,2016 Page 1 of 2 k:\Handouts\Permit Application