17-104004 ❑Federal Wa
TYGF y PERMIT REceivE9CO ME PL DE EN P
COMMUNITY DEVELOPMENT SERVICES APPLICATION
253-835-2607•FAX 253-835-2609
AUG
1 8 2017
CITY OF FEDERAL WAY
SITE ADDRESS COMMUNITY uEvELOPMEN SUITE/UNIT#
3 L 5i 2, 5 hate A-U6 , Fedi-fro-4 tray
PROJECT VALUATION ZONING ASSESSOR'S TAX/PARCEL#
$ 5,00a O ? 6- 0 0 SD
TYPE OF PERMIT ❑ BUILDING ❑ PLUMBING 0 MECHANICAL
❑ DEMOLITION ❑ ENGINEERING I1Z4 FIRE PREVENTION
NAME OF PROJECT
(Tenant Name/Homeowner Last Name) /�c. krak,c tirOQ ro,�iC
/`4 l• 1
br 42vttirti-l• S e, ('ods.
{atul' t-n .
PROJECT DESCRIPTION �� (�
Detailed description of work to
be included on this permit only
NAME PRIMARY PHONE
PROPERTY OWNER
MAILING ADDRESS E-MAIL
CITY STATE ZIP
NAME PHONE
1Cw- Sw110,i !t- Z.S`* _
- €317.-€317.---Zretos
MAILING ADDRESS VJ E-MAIL
CONTRACTOR 32S- tA,44 ,41-Anin Avg- 5 tic ,)L
� 4 f-i , @ pl.S� ieC,�
6e.
CITY ,Le L / kfL)STATE ZIP SO3 FAX 5 /04,k—
WA STATE CONTRACTOR'S LICENSE# •1J•"1 EXPIRATION DATE FEDERAL WAY BUSINESS LICENSE#
/ /
NAME PHONE
VA , t.%,15 -V 4- 2.53'-. t`�L-1cloc,j
MAILING ADDRESS J
APPLICANT E-MAIL
Sac .�ws141tov. Avf- 5 q ` >.,t-11"(5e o sou6Iec1w i
CITY STATE ZIP FAX it)6r
t<-GWt 1.00% ISO 32
PROJECT CONTACT NAME C l PHONE
" J
(The individual to receive and Yr' w i q O i- 4S-3 4371 r I'IO j
respond to all correspondence MAILING ADDRESS J E-MAIL
concerning this application) 32 .. h l�•gtoh I�Q, S 9 A w-�,Y,q _...s se `eIe t —. t
CITY J STATE ZIP FAX �/1
KQ)4'E' lA-.)c� 88032
ALTERNATE CONTACT NAME: PHONE E-MAIL
PROJECT FINANCING NAME
0 OWNER-FINANCED
Required value of$5,000 or more
IRCW 19.27.095) MAILING ADDRESS,CITY,STATE,ZIP PHONE
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.
Ifurther 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.
SIGNATURE: �-;, --�` �+ - DATE ea' I—-- I
II
PRINT NAME: Rican St-o;i 4.'
Bulletin#100—January I,2011 Page 1 of 3 k:AHandouts\Permit Application