12-102148 • - / 6ai ±Ai
CITY OF PERMIT SF MF CO ME PL DE EN c
Federal Way
COMMUNITY DEVELOPMENT SERVICES APPLICATION RECEIVED
253-835-2607•FAX 253-835-2609
www.atuoffederalivau.com
SITE ADDRESS MAY 15 2012 SUITE/UNIT#
33 507
9— Ave 5 CITY OF FEDERAL WAY C--3
PROJECT VALUATION ZONING ASSESSOR'S TAX/PARCEL# CDS
$ 757 C» -
TYPE OF PERMIT ❑BUILDING 0 PLUMBING ❑ MECHANICAL
❑ DEMOLITION 0 ENGINEERING 11ir FIRE PREVENTION
NAME OF PROJECT I�
(Tenant Name/Homeowner Last Name) ('Q s C)T f,'G p L L C.
Fire alarM I terAnt i ri ororemerit
PROJECT DESCRIPTION
Detailed description of work to
be included on this permit only
NAME
PHONE
PROPERTY OWNER aeiller$j1.e/I d'N.ctiof f 223- £39-1120
ESS 14,‘ E-MAIL
MAILING
3 507 9 Ave 5 .S,.i fe 6 I Jar yy®6afersAel%;ehols.e.91
CITY STATE ZIP
Fey/era' 614 WA 9g 0O3
NAME PHONE
Every—eve, E're 4/4rrrlS
CONTRACTOR MAILING
7ADDRESS 50„th J Street E-
CITYSTA FAX
T orna ti✓ 8¢()9
WA STATE CONTRACTOR'S NSE# EXPIRATION DATE WAY BUSINESS LICEN�BL Ih- .
EVE-KG FA OP G 6 � g � 12
NAME PHONE
Evergreen
APPLICANT
MAILING DRESS E-MAIL
CITY STATE ZIP FAX
PROJECT CONTACTNneE 1 )_^
(The individltnl to receive and �J O n n a q IC z53 6 Z 7 -3791t
respond to all correspondence MAILING ADDRESS E-MAIL
concerning this application) Jadgr'+f()e✓er teen I;rQ.C0/'11
CITY STATE ZIP FAX
ALTS TE CONTACT NAME: PHONE E-MAIL
—
PROJECT FINANCING 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.
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 ci as a part of this application.
SIGNATURE: ; /Y' C1 DATE c l5 !
PRINT N /b/ 1< &A22
Bulletin#100—January 1,2011 Page 1 of 3 k:\Handouts\Permit Application