17-104081 74„,„„lk.,..., PERMIT APPLICATION
CITY OF
PERMIT CENTER+ 33325 8th Avenue South + Federal Way,WA 98003-6325
Federal Way 253-835-2607 + FAX 253-835-2609 + permitceritel cREffVytC way.com
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PERMIT NUMBER 1 t 0 40 c6 ( - FP AUG 2 3 2017
!!! _ _ _ TARGET DATE CI 1 y OF FEDERAL WAY
SITE ADDRESS G°441IMPLEYELOPMENT
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$
PROJECT
rxV'ALUATION ZONING ASSESSOROS TAX/PARCEL# a 4 _ 9 2
TYPE OF PERMIT ,_,,BUILDING ❑ PLUMBING ❑ MECHANICAL ❑ DEMOLITION ❑ ENGINEERING ,FIRE PREVENTION
NAME OF PROJECT N( (C- C6-Air tL' e
PROJECT DESCRIPTION ,.,-) C_Wigi__
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Detailed description of work to .5/4 /0 L C-
be included on this permit only
NAME PRIMARY PHONE
PROPERTY OWNER /V wL ( /�,f�I A./It -7_,�/ (-L
MAILING ADDRESS rE-MAIL
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CITY STATE ZIP
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AME PHONE
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MAILINGLIADDRESS /r / E-MAIL /�
CONTRACTOR !a/ L' /T O t ill �Jf A' /� so,.../ 7--E2 CO �j 1 ,,.3C iK-C'�('� �1
CIT STATE ZIP yv FAX
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WA STATE CONTRACTOR'S LICENSE# EXPIRATION DATE FEDERAL WAY BUSINESS LICENSE#
ISiF,EFS 8(1,17F l2 / .31 /17
NAME PHONE
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APPLICANT MAILING ADDRESS E-MAIL
CITY STATE ZIP FAX
NAME PHONE q G
PROJECT CONTACT i.C IL ✓RL-2 C-_ 'f ex-S'S' /- (f! C/
(The individual to receive and MAILING ADDRESS E-MAIL
respond to all correspondence cdGil(-2 '7,1#t C?
concerning this application) CITY STATE ZIP FAX
NAME
PROJECT FINANCING ❑ 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 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 patt of this application.
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SIGNATURE: yr�DATE e-/ -•Z 3-/
PRINT NAME: -R t CIL r ''t 0
Bulletin#100-January 29,2016 Page 1 of 2 k:\Handouts\Permit Application