14-105079 4111/
RECEIVE41111
�,TYOF r PERMIT APPLICATION
Federal Way OCT 01 6.0i,-.
f /// CITY OF FEDERAL WAIF nVP
PERMIT NUMBER / 'I./ _ / 0 .+� 0 '7 9 - ± P (9 /_ �)Ll'LL
�J TARGET DATE l7 l! • C40 I
SITE ADDRESS SUITE/UNIT#
S j 1 O J. . 3'O`'''S t• Fe.clebutts
PROJECT VALUATION ZONING ASSESSOR'S TAX/PARCEL#
$ 1 z.,g4co 9 J- CO 4- R o - a 5 c - d
TYPE OF PERMIT ❑ BUILDING ❑ PLUMBING ❑ MECHANICAL ❑ DEMOLITION ❑ ENGINEERING ( FIRE PREVENTION
NAME OF PROJECT I ► 1.i !.l Crus(] KesiJ Q ,t /Fr b „ /1 o n
S S
PROJECT DESCRIPTION n9-rt O f ri re- Supp res‘ton tem , • Ix 13 D
Detailed description of work to (Cu.) Czhjtr A.Ct'i DN-161, le t , I es Nene.-.
be included on this permit only
y-e cl, f - -tawu ss-r,
NAME PRIMARY PHONE
PROPERTY OWNERVLStry e_. )53- 97(0833 3
MAILING MESS E-MAIL �"
/��J 1'D nici-utboCoristrr,�choq
CITY ST TE ZIP vi: '/le'/'
PHONE
NAME Zi 1-1,1„e_ ! h,L.m.be_A- 4 e-b =25-3-Pt-1 7.1-3ci
MAILING ADDRESS E-MAIL
CONTRACTOR ' S 179 a' dod j(Jri c.e the p11�f•beY0
TATEFAX
CITY ��.Gc. -L s - ZIP gS3 3 g �53�41R0- 3/3 7 •0.0 t
WA STATE CONTRACTOR'S LICENSE# EXPIRATION DATE FEDERAL WAY BUSINESS LICENSE#
ICI CAC PCsce5a KA/ / / 2O-II-JO31DIO Oa-6L-
NAMEPRIMARY PHONE
Kt C/t• 1411-, fes!Willie
APPLICANT MAILING ADDRESS E-MAIL A
CITY STATE ZIP FAX (//pA-J/`N/��u VVV
NAMEPRIMARY PHONE
O
PROJECT CONTACT Tic.,-n,b/i►1
(The individual to receive and MAILING ADDRESE-MAIL 0197.
J f irespond to all correspondence poS 7 Ra— vconcerning this application) CITY sTATE zIP FAx
41,4
NAME
PROJECT FINANCINGEl OWNER-FINANCED
Required value of$5,000 or more MAILING ADD S ,A 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: 7 / DATE
D/v
PRINT NAME: d Z i-n4//ri
Bulletin#100—January 1,2013 Page 1 of 3 k:AHandouts\Permit Application
103
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Fee 2,36.6-6 > 34O + c9.)14- •00= IL5$1 D !v1' 6tz.bmitt -1