16-101004 • •
CITY OF �; PERMIT APP�' TION
Federal Way
(`� FEBI 2 5 2016
PERMIT NUMBER I _ ( " ` _ OF FEDERAL WAY
TARGET ISA CDS
SITE ADDRESS SUITE/UNIT#
13 t U S 3 z, - 4 5--/ Fe clev-zI )4:
;> wr k�vo-3 A-11.1-
$
PROJECT VALUATION ZONING AS SOR'S TAX/PARCEL#
i, IZ�-. I6 l S o o c o - 0 0 7- 0
TYPE OF PERMIT ❑ BUILDING ❑ PLUMBING ❑ MECHANICAL 0 DEMOLITION 0 ENGINEERING KFIRE PREVENTION
NAME OF PROJECT I
�,C l eb r�O✓1 (e,uttt,11'` - F.r-e e do..ii .i-{-tie ss T. T
PROJECT DESCRIPTION I�r h 24� ,vvi Pro 2.Wit-11-i- + aria u1 vi of;Pi\c,•0.3-i"0.1 -I-0
Detailed description of work to `T . 5/-tti.Qciii Ce'#-NCS: -sp ace.
be included on this permit only
NAME PRIMARY PHONE
PROPERTY OWNER ?V'SC.,Ail VI VL4 hilt V1+-5 (S o i) q 7-3 - oz Lt k
MAILING ADDRESS E-MAIL
till 51v 501nvic0
CITY STATE ZIP
?Or+-laOr) O Z (47-u
NAME PHONE
Li a 41;n(kip vi At avvil ro i. . e-7-“) z...5.-/ . 5 3 ,.
MAILING ADDR S I E-MAIL?i ,ra-ii0
CONTRACTOR VO40 A- r131004 t.) j 5 ..i 11;nq to' �Ia,rvr.. c c•^�
CITY STATE ZIP FAX •J
Sezkkl� LO P+- elici3I-+ OWL-) 32.z- 77iI-I
WA STATE CONTRACTOR'S LICENSE# EXPIRATION DATE FEDERAL WAY BUSINESS LICENSE#
(4) 17 /. / 16, z-o •-mac? - 1_42i -et -cx,--+cit
NAME -� A 1 -VV PRIMARY PHONE
k l S 11 V I VI AM. ) T✓I L. I='z )O , 3 z-ir-3 Z'Fsi6
MAILING ADDr�sS E-MAIL;AN.,it Ct.,
APPLICANT
2,0 ASLO / ;, pat-4- to, 5 La.1.liir.(t�it76i 1- a-l7�Yw+�.Gies
CITY STATE ZIP FAX �J
Vii'> _ WA- iCiis134 7-QbJ3zZ.- 9Zf 4
NAME PRIMARY PHONE
PROJECT CONTACT ->_ VI S W:WV,+ Lt.06) 4 ate 53 3 2
(The individual to receive and MAILING ADDRESS E-MAIL i,5}L.£,.i e
respond to all correspondence ?.A.)-;0 O .4-i' pcJ-4- LA) 1- 5 ini,6 /i oci t ort a l z"'lel,/. (..4."-.17
concerning this application) CITY STATE ZIP FAX U
4-4
,e3—. � Pt '613`-I mak?_3z -z( H
NAME
PROJECT FINANCING 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 to the city as a part of this a lication.
DATE L / t,� I L6
SIGNATURE:.__C: ,=:.- I'
PRINT NAME: all �r W ' V'T
Bulletin#100-January 1,2013 Page 1 of 3 k:AHandouts\Permit Application;