16-106097 • •
PERMIT APPLICATION
CITY OF �•
PERMIT CENTER+33325 8th Avenue South + 1 98003-6325
253-835-2607 + FAX 253-835-2609 +permitcenterrwcityoffederalway.com
LEC 2 'l 2016
PERMIT NUMBER l V _ ` 0 V 0 '7 TARGET DATE frt) rt-DFPAL WAY
SITE ADDRESS SUITE/UNIT#
k-3• k 33,56 S. 3?,'-1z SM,
PROJECT VALUATION ZONING ASSESSOR'S TAX/PARCEL#
TYPE OF PERMIT ❑ BUILDING ❑ PLUMBING ❑ MECHANICAL El DEMOLITION ❑ ENGINEERING FIRE PREVENTION
NAME OF PROJECT
Why Lk( SO-rtvlc
PROJECT DESCRIPTION �I 6^ A-D�-` l ! [-CZ is 11 �t_�y C r C/C C h l?CX,)2.s I.v 1-6
Detailed description of work to c.fL- N(N(L N `JYSPC-rte .
he included on this permit only
--
NAME PRIMARY PHONE
�k'e-scU t �vkf 5-r ? GPC& 1C-'S C_t_L
PROPERTY OWNER MAILING ADDRESS E-MAIL
►mac' `(? 4 27 CaC.(
STATE ZIP
C� _ 7 c
_.-._-_-----_ NAME PHONE
1-]R-e-7 Z(14-6
MAILING ADDRESS E-MAIL
CONTRACTOR Ov,4Cn (Rc r�Cy(` 1Z.$J •'`j S 'TF '
CITY STATE ZIP FAX
WA STATE CONTRACTOR'S LICENSE# EXPIRATION DATE FEDERAL WAY BUSINESS LICENSE#
'cs I r `Si.J\S1.6.5 l ) Co / /Cn / I `) 19-`57 •(1-356(4>(`l Sitio L-
NAME PRIMARY PHONE
Np'1-(-
APPLICANT MAILING ADDRESS E-MAIL
CITY STATE ZIP FAX
-- -- --- — NAME PRIMARY PHONE
PROJECT CONTACT 2-5 3-9 S'Y'4000 S/
(The individual to receive and MAILING ADDRESS E-MAIL
respond to all correspondence fv,477—C45`/sTl-,St/L-' T.Ca-z
concerning this application) CITY STATE ZIP FAX
-_----- NAME
PROJECT FINANCING ❑ OWNER-FINANCED
Whenvalue is$5,000 or more MAILING ADDRESS,CITY,STATE,ZIP PHONE
(RCM 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 s ch claim),which may be made by any person, including the undersigned,and filed against the city,
but only where such claim ar'- = out of the reliance of the city, including its officers and employees, upon the accuracy of the
information supplied tot e c s a part of this application.
SIGNATURE: DATE /,0,2A,
PRINT
.2/2 2// .-
PRINT NAME: /f.4-TT- 4 4-/t'f"'4A/
Bulletin tt 100 January 29,2016 Page 1 of 2 k:AHandouts\Permit Application