13-102351 CRY aF A . ' L./
Federal PERMIT SF MF CO ME PL DE EN •
CAnrMUWrrr DEVELOPMENT SERVICES APPLICATION
253.8352607•PFlX 25S_8_-_BQB.9 2013
my OF FEDERAL WAY
SITE ADDRESS CDS
SUITE/UNIT•
&b5w thai ca'agt4.
PROJECT VALUATION ZONING ASSESSOR'S TAX/PARCEL 3
TYPE OF PERMIT 0 BUILDING 0 PLUMBING 0 MECHANICAL
0 DEMOLITION 0 ENGINEERING j FIRE PREVENTION
NAME OF PROJECT
(Tenant moi/ /"•.
(Tenant Name/Homeowner Last Name/ 54 la s ( T( ' . fi{ Toult, T 1 �" 1 .
err* (l'J 1E. FxtsrA.61,
PROJECT DESCRIPTION
+
Detailed description of work to r O �' . " Lrt "h c• 1i
be included on this permit only
NAME PRIMARY PHONE
PROPERTY OWNER
MAILING ADDRESS EMAIL
CITY STATE ZIP
NAME 7 Ode/
_{ PHONE
MAILING ADDRESS j .. f .
CONTRACTOR 107 I��faitmer
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CITY ZIP+)IS'y4fdoe/ FAX
a h
WA�R CONTRACTOR'S�� � � I,,,,,g�TION DATE FEDERAL WAY BUSINESS LICENSE e
NAME 1 .
PHONE
APPLICANT MAILING ADDRESS E-MAIL
CITY STATE ZIP FAX
PROJECT CONTACT NAMEi. PHONE
(The individual to receive and
ft+�/ 1 j--tea-z 7
respond to all correspondence MAILING ADDRESS EMAIL
concerning this application) ' a �✓Ll " I1theM " iT�ti
CITY STATE ZIP FAX '*✓
ALTERNATE CONTACT NAME: PHONE E-MAIL
PROJECT FINANCING NAME
Required value of$5.000 or more 0 OWNER-FIIYANCED
010W 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 support of this permit application is true and correct.I certify that I will comply with
all applicable City of Federal Way regula', pertaining to the work authorized by the issuance of a permit.I understand that the
issuance of this permit does not remove he owner's responsibility for compliance with local, state, or federal laws regulating
construction or environmental laws.
'further agree to hold harmless ' /4. of Federal Way as to any claim(including costs,expenses,and attorneys'fees incurred in
ir
the investigation sued which may be made by any person,including the undersigned,and filed against the city,
.40000:
but only where ,information •,.. 1..", .��application.reliance of thcity, including its officers and employees, upon the accuracy of the
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1�1.r41111 —
'of
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SIGNAT� L, s A ..� DATE
PRINT NAME: r —.So Ir [/4___
Bulletin#100-January 1,2011 Page 1 of 3 k:\Handouts\Permit Application