13-103415 ilf CEIVED
•. PERMIT APPLICATION
CATION
�� AUGFederal Way 02 2013
CITY OF FEDERAL WAY
CDS ^
PERMIT NUMBER / 3 _ / 0 ± „/J - F
TARGET DATE
SITE ADDRESS SUITE/UNIT it
33526 1 711 Ave_ S. CC - Vw7, LvA 't003
PROJECT VALUATION ZONING ASSESSOR'S TAX/PARCEL it
$ 7ct5_ 06 ii 2 G W k 0 - o I 2 5
TYPE OF PERMIT ❑ BUILDING ❑ PLUMBING ❑ MECHANICAL ❑DEMOLITION ❑ ENGINEERING X FIRE PREVENTION
NAME OF PROJECT o f i o k
PROJECT DESCRIPTION Qe'�I t exi c1- - .s TU w . Ae s re,G�ic�
Detailed description of work to
be included on this permit only
NAME PRIMARY PHONE
PROPERTY OWNER ()Hai- (z63) 6G I - ie0S
MAILING ADDRESS E-MAIL
3 2(0 q 7'i ive 5.
, ITY STATE ZIP
htl)tl-Cil Wo., W r1 'Ot93
E PHONE
2ll�.rw‘ Cep -r rVVC. (xoo) 35,1-1555 cxi- 037
MAILING ADDRESS E-MAIL
CONTRACTOR PO Box 31-101 S4. soh Qtilcr.!`w,Ceurit,C AC•t-t,"1
CITY STATE ZIP FAX
Lei.CL y I.J4 °►`66 O Cj
WA STATE CONTRACTOR'S LICENSE S EXPIRATION DATE FEDERAL WAY BUSINESS LICENSE II
ALARI1GT055G6J 02. / 19 / 15 2o•150-I0I41S2-oo-3L
NAME PRIMARY PHONE
-5e40ft A • o i.. (t'Oo)35y -153'5 Co 6337.
APPLICANT MAILING ADDRESS E-MAIL
?o Box 34 07 sAmottrso,@c lan+,Ceh1•6'rvic•Cv")
CITY STATE ZIP FAX
I,sCei ft- a(4 b°61
Cl-(TNAME PRIMARY PHONEv4 Y_ k
PROJECT CONTACT 6G vt Q PP/i'c C' 'Cl-
(The
he individual to receive and MAILING ADDRESS E-MAIL
respond to all correspondence
concerning this application) CITY STATE ZIP FAX
NAME
PROJECT FINANCING 0 OWNER-FINANCED
Required value of$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
�tothe cityci�as a part of this application.
SIGNATURE: /. �t/ �� DATE 7/3)1 t.3
PRINT NAME: ,LD Au4 t Sc
Bulletin#100-January 1,2013 Page 1 of 3 k:\Handouts\Permit Application