16-103188 CITY OF . .;;.,
4%,
• PERMITtiPPLICATION
±� Way PERMIT CENTER+33325 8th Avenue SoutIR erE " 6 8003-6325
Federal253-835-2607+FAX 253-835-2609+permitcente1 cityo e.er. way.com
JUL 01 2016
PERMIT NUMBER l — ( ( ges FT>_ TARGET DATE CITY OF FEDERAL WAY
CDS
SITE ADDRESS SUITE/UNIT#
3?ix- 32,o , St-)4. aim ( , NE)
PROJECT VALUATION ZONING ASSESSOR'S TAX/PARCEL#
$ i
TYPE OF PERMIT ❑ BUILDING 0 PLUMBING 0 MECHANICAL ❑ DEMOLITION 0 ENGINEERING hrFIRE PREVENTION
NAME OF PROJECT FA-2-4,-AS .I 1.47 F__ Per 1:5-_ f- C.V/J1
PROJECT DESCRIPTION P�7 r A. PLA2e)'"z T l — �e-tA) or Fl L_ ATS
Detailed description of work to -D (as
be included on this permit only
NAME PRIMARY PHONE
.,35- --Ti 4 Z E5704_S
PROPERTY OWNER MAILING ADDRESS E-MAIL
3,24'5 3a,Ja 441 S
CITY STATE ZIP
FeO 44 t)A-f tjA- II°0
NAM NJ iN. r e.Arl���6-1rfs Las-a-7.9 aas0
MAILING ADD S E-MAIL
`'f , 1-14-P LteA �J L 3 -(Ct> di.>,1t„e,..�►.¢�f_ ''
CONTRACTOR •
CITY STATE ZIP FAX
t 9'6 05-7 qa5-?S I -0,-7 I-fC.t
WA STATE CONTRACTOR'S LICENSE# EXPIRATION DATE FEDERAL WAY BUSINESS LICENSE#
600\ltrt_gl14 Eq ( / I$ / i8' 20-otr-Io2-13s'-8L _
NAME PRIMARY PHONE
sits -.
APPLICANT MAILING ADDRESS E-MAIL
CITY - STATE ZIP FAX
NAME PRIMARY PHONE
PROJECT CONTACT 'DPW E C 0253--Lf)I 'L'I4.a 'i
MAILING ADDRESS Lal hir-
(The individual to receive and 44-J A)t s' ./(� E-MAIL 04.44t.& za. ) `
respond to all correspondence /7
concerning this application) CITY STATE ZIP FAX
SAV.) G g8os-7 4 �-�5( - i9 `K;
NAME ._ _._.. _ _ _
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 arty 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.
SIGNATURE: 1' �
DATE �'J I //4/
PRINT NAME: -,[ -ItJt Co l..e%I'K V._
Bulletin#100-January 29,2016 Page 1 of 2 k:\Handouts\Permit Application