16-102616 4
,fix PERMIT APPLICON
Fe�[eral
{{ MAY 31 2016
PERMIT NUMBER 140 _ / 0 7(0 / `f' _ `FPCITY OF FEDERAL WAY
TARGET DATE ' CDS
SITE ADDRESS SUITE• /UNIT# _
a0/0 S. 3v1l'4 f/8 ./37. >
PROJECT VALUATION ZONING ASSESSOR'S TAX/PARCEL#
$
aa��o� b —5— 3 2 - < o o 0
TYPE OF PERMIT 0 BUILDING 0 PLUMBING 0 MECHANICAL 0 DEMOLITION 0 ENGINEERING ,,,,��((
l�FIRE PREVENTION
NAME OF PROJECT apt 1Z1k4E.-16(.04) ovi T$13 m4'Zz 4 411 0.1i
PROJECT DESCRIPTION /rlcn1 f y 77 t e/S�1v - $Pie/n/� _VS I
Detailed description of work to AreawntriongrE ' .�tatthriEZ4
be included on this permit only
•
NA= PRIMARY PHONE
&ZE610i214/OLD/NGS LLC J gr3- lis-z-/
PROPERTY OWNER MAILING ADDRESS E-MAIL
x/00 G AUS SW i uu1figal p6Gf�►ecy aheorn
CITY 50/41/
2/ -/ STATE ZIP
NAS 94itI ues 7ewij . ---1-.72e-...267g
PRONE
cl
CONTRACTOR//p�ILING ADDRESS/4tE£ _ 7P'illiL* 'i �.4 +
� 4 14)if STATE
ZIP/a47 '2V F p ~9o2o_ J v
WA STATE CONTRACTOR'S LICENSE A ENATION DATE FEDERAL WAY MISTRESS LICENSE A
5101/6105/342r _Ii- / / /4 /2-81-oaocsc O)-84.
NAMEPRIMARY�/7N Fief SVST�is aye ale
APPLICANT
MAILING �l je or 1 ' I f/fe.(�
STATE ZIP-
c17-7-444044 &4 wig,/___ FAX
as-s—d`-dna)
_ 7
NAME PRIMARY PHONE
' _-
PROJECT CONTACT ItFF SM l g$j-awe- OC77
individual to receive and MAILING ADDRESS E-MAII. ,�f
respond to all correspondence 1/96 SZ/f4..r1/& g C �'J I SWM�
concerning this application) CITY
nit BT ZIP grTa7y FAX
7
_
PROJECT FINANCING 0 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 part of this application. f
SIGNATURE: 9,29'J/L111
DATE �7w
PRINT NAME: AFF 51.14 114
Bulletin#100-December 29,2015 Page 1 of 3 k:\Handouts\Permit Application