12-103932 RECEIVE® I2- 1 O 9 &2•
CITY OF PERMIT SF MF CO ME PL DE EN FP
Federal W
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COMMUNITY DEVELOPMENT SERVICES APPLICATION /
253-835-2607•F 8.c0F9 _ tC ��4
�u,�v.cItvorre���F FEDERAL WAY L/L��//yy"GGrHH- ,AAII II�L/��//)"ii '�,t'
CDS , S-s-
SITE ADDRESS SUITE/UNIT' #
f239/7' /f-/" Way 5
PROJECT VALUATION ZONING ASSESSOR'S TAX/PARCEL#
$ 2 5---- k_ se5 ' 7d
TYPE OF PERMIT ❑ BUILDING ❑ PLUMBING ❑ MECHANICAL
❑ DEMOLITION ❑ ENGINEERING 1 'FIRE PREVENTION
NAME OF PROJECT //�) PPROn
p7
(Tenant Name/Homeowner Last Name) /// i��// _/ 1/�� /�C/C /7 ( e
I)
PROJECT DESCRIPTION
Detailed description of work to ,�1'���� !� {r / �,11;4 4' 7/0/all
be included on this permit only
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i 1i n�(/ - A / / w
Y
NAME e---.e---. PRIMARY PHONE
PROPERTY OWNER A/I_ �7�44/ 24ve./�� ,eJ
MAILING ADDRESS 1 E-MAIL
CITY STATE(, ZIP �" }�
NAME 7 7 C /,/J/ `/ V - L /I .. PHONF� — p)3—` / /
MAILINGG ADDRESS / J / g_ r ,y�,����/t
CONTRACTOR 2 ofd Fra-,7/4c Q� A i/ /2A/,i(f i�l/tof[/f 4- ,544e �i ,,
CITpCy1c � 5.3 _.7.4f___
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WA STATE CONTRACTOR'S LICENSE# EXPIRATION DAT FE ERAL WAY BUSINESS LICENSE#
rireJ<✓I'ISIG* /2 / 3( / iZ l�f?-Dater-- /y yes
NAME /. / �rA I J/ PHONE
(� ./s4 /�
APPLICANT MAILING ADDRESS E-MAIL
CITY STATE ZIP
PROJECT CONTACT NAME //1...6el PHONE
(The individual to receive and
respond to all correspondence MAILING ADDRESS E-MAIL
concerning this application)
CITY STATE ZIP FAX
ALTERNATE CONTACT NAME: PHONE E-MAIL
PROJECT FINANCING NAME
❑ OWNER-FINANCED
Required value of$5,000 or more
(RCW 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.
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 - art of this application.
SIGNATURE: DATE r' y- /2
PRINT NAME: ai, t/ T^f71��9
Bulletin#100—January 1,2011 / Page 1 of 3 k:\Handouts\Permit Application