17-104274 N
PGromir
ti PERMIT APPLICATION,.,
CITY OF
PERMIT CENTER+33325 8th Avenue South+Federal Way,WA 98003-6325
Federal llVa 253-835-2607+FAX 253-835-2609+peRi�Plt'IRIt'�girjvD alway.com
T _ 1 0 L ' 4 _ l�� SEP 062017
PERMIT NUMBER- - _ _ TARGET DATE
CITY OF FEDERAL WAY
COMM Nf1Y DEVj.QPMCAfr
Et,
SITE ADDRESS a. S ,..0 SUITE/UN
PROJECT VALUATION ZONING ASSESSOR'S TAX/PARCEL# � � �-
q' I a 1
TYPE OF PERMIT 0 BUILDING 0 PLUMBING 0 MECHANICAL 0 DEMOLITION 0 ENGINEERING 4E PREVENTION
NAME OF PROJECT 6,4lit b td a 41 X;
PROJECT DESCRIPTION F .ro., A[0,4-ON Sus 1M itaf 66zIMP'w4—•
Detailed description of work to (d 1
be included on this permit only
NAME PRIMARY PHONE
Eckv E k/ oc i wwv Hca ZS3-79L-OSS3
PROPERTY OWNER MAILING ADDRESS E-MAIL
t1n Q, S. 320 *' si---.
CITYwer G \,J 1"TE TT. Z l $OV
NAME
COSICOFire✓ pra-�cc-tio� 206- a.-_" _ 3360
MAILING
ADDRESS S -
E-MAILE �1
CONTRACTOR 430/31 S• 13
la. Placa- V- o o.o.,sc c .c
C.,7__u�� �QVST TE ZIPil, 1` 68 FAX q33-33E6
WA
CONTRCENSE#ACTOR'S
SSS EXPIRATION� 11 DATE FEDERAL
O o%-01BUSINESS
89 LICENSE
oo eL
NAME
®�Se�► PRIMARY PHONE
Zo6 q38-337K
APPLICANT MAILING ADDRESS E-MAIL
y 30 g S. 13 Ist, Place„ Kan o(Sem @C-O$'O ..cors.
CITY Tukt..46. \x Z 616 6- (f38 -33s1
NAME
PROJECT CONTACT �� O`Ah ZY PHONE
y 38 337e
(The individual to receive and MAILING ADDRESS c g�E-�MAIL /�
respond to all correspondence LI 20 v' 13 I s+' 'lac.. I�PJV+OISP P� �CO1kQ .C000%
concerning this application) CITY STATE ZIP FAX
-u kwilu WA GI M E' zo(o- '-(3$- 3356
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 • the city as a part of this application.
SIGNATURE: ' r DATE —Z6/7
PRINT NAME: 6
Bulletin#100—January 29,2016 Page 1 of 2 k:\Handouts\Permit Application