10-100859 RECEzvii
arra _
\1AR 0 4 2010 A - /. .6 1 5- ?
Federal Way PERMIT SF MF CO ME EL PL DE ENTP)
COMMUNfrY DEVEIAPMENT S1:Y2lNCE5 OF FEDE a 'LI CATION /
253-835-2607•FAX 253-835-2609 CDS
uauu;.citu»lferlercimau.com
� ,r'!:: :4''''''''':'N'; ..,., x, ,.,,,,9,. I���.?; ,wE, ,.r„$ .:.:,,, ,,,, `'�. i, �.� fir�'�'��:'„ �:.o,,. �z��',� ,3 s 3�'�� n4,,
d
SITE ADDRESS
140 0 S 520 SA- 2.d c t 4,,, i ii..” 1 %0 o
SUITE/UNIT# ZONING ASSESSOR'S T�AR�# --./
v �
..' ",. P�. ,
: -r tiro , �,"�ri,, ;r'�a �� '0,041#44',f$ *r��� �.h: ;� ��?� �.,, '` ,, l
NAME OF PROJECT
(Tenant or Homeowner Name) x--- ,\cASV,,� ,,
❑BUILDING ❑ PLUMBINGCHANICAL
TYPE OF PERMIT ❑ DEMOLITION ❑ ELECTRICAL ❑ ENGINEERING AFIRE PREVENTION
A +o1 -civ 'moi y e �t-I r.L.r'r� '6i' -e-.�r�
PROJECT DESCRIPTION
Detailed description of work to 11,
be included on this permit only ,
9 / - di',F i73 S f f 3 :fgni/r1�d E JJ,G"
NAME y PRIMARY PHONE ..
PROPERTY OWNER EQ.G`E S A Pf 1042.4 Y'i e2'S ( ) -
MAILING ADDRESS,CITY,STATE,ZIP 1 E-MAIL
i 00 D wok SA—. 5 -i rliparl 15G
OWNER IS ALSO: ❑ CONTRACTOR APPLICANT 0 PROJECT CONTACT
NAME PRIMARY PHONE
A!2y ! Sea.f�V.if ( ) -
CONTRACTOR MAILING ADDRESS,CITY,STATE,ZIP FAX
11 29 N • Ce rkr.,c � 0 10S ( ) -
WA STATE CONTRACTOR'S LI ENSE# E !RATION DATE FEDERAL WAY BUSINESS LICENSE#
('� !�� /2Z/ t t
NAME PRIMARY PHONE
APPLICANT �� (26j)(ljr s—ir b
MAILING ADDRESS,CITY,STATE,ZIP FAX
PROJECT CONTACT NAME C_' PRIMARY PHONE
(The indwidual to receive and -Lew vt�.- f.,..,„ 1)t SCA{ ( ) -
respond to all correspondence MAILING ADDRESS,CITY,STATE, FAX
concerning this application) ( )
ALTERNATE CONTACT NAME: PRIMARY PHONE E-MAIL
( ) -
PROJECT FINANCING NAME
0 OWNER-FINANCED
Required for projects with
value of$5,000 or more MAILING ADDRESS,CITY,STATE,ZIP PRIMARY PHONE
(RCW 19.27 0951
( )
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 suppli= he c' as , •art of this application.
SIGNATURE: �n►..-�:�rs_�� ly' DATE 1 /I V
PRINT NAME: I�,y_�A. r- `
-
Bulletin#100—January 1,2010 Page 1 of 4 k:\Handouts\Permit Application