11-101820 a1 g2a
i PERMIT
Ilk:IEdEt\
EN
Federal Wav
CONEVMNITY DEVELOPMENT SERVICES APPLICATION
2.53-83.5.2607•FAX 253-835-2609 MAY . 1 2011
r IeH/r c554) OF FF ERAL WAY
SITE ADDRESS ITE/UNIT#
6 � .� C4 c) - 2 ..3
PROJECT VALUATION ZONING ASSESSOR'S TAX/PARCEL#
$ c31 0 °O i 3 z ! Ss _ 00 o
TYPE OF PERMIT
0 BUILDING 0 PLUMBING 0 MECHAAL
0 DEMOLITION 0 ENGINEERING FIRE PENTION
NAME OF PROJECT /. Q/'1�1 p u S f o/i?t
(Tenant Name/Homeowner Last Name) (�. r
PROJECT DESCRIPTION re. Vi S-6%.t` a xs 1 S'�'1 1.13 T Cil t Gly' wS y M
Detailed description of work to �J
be included on this permit only
NAMES 0 `(<N. 1>A* PRIMARY PHONE
/LYl
PROPERTY OWNER
MAILING ADDRESS E-MAIL
CITY STATE ZIP
NAME 1 PHONE
Meri1ia4 Sect 4-y f l€c+6c. 253 cp38
MAILING ADDRESS 1 E-MAIL -
CONTRACTOR PO Bo S '`n ICITT
,e".4-- . WA ZIP 980q2.-
8o qZ FAX
6,3 C 316
WA STATE ETRACTOR'S LICENSE# EXPIRATION DATE FEDERAL WAY BUSINESS LICENSE#
Mei,4-S-e 0a4:7d ' 20-o6 100155-
NAME ` PHONE
5cten - as a.bo v e. (Cot, .c40\r" \)
APPLICANT MAILING ADDRESS E-MAIL
CITY STATE ZIP FAX
PROJECT CONTACTNAME 1.4 C �f
(The individual to receive and Ck S PHONE
5 3 63 8 m 7` a
respond to all correspondence MAILING ADDRESS E-MAIL
concerning this application) ?d 6O)4 11'? a,lfeCl,.•/ •ia02.
CITY STATE ZIP FAX
"'R 9150'f2. 253 (.035 •336
ALTERNATE CON ACT NAME: PHONE E-MAIL
5-k e. ,NAME:
WWnt s-feurii��a.�,trcu.y .laL
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.
T 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 city as a part of this application.
SIGNATURE: — DATE /1--1 5-[ 1 -1
PRINT NAME: f l Of e°✓I C€ f eu-+'--1 s
etin#100—April 14,2010 Page 1 of 3 k:\Handouts\Permit Application