17-105285 ‘,
PERMIT APPLICATION
CITY t
Federal Way PERMIT CENTER+33325 8th Avenue Souticulp + 003-6325
253-835-2607+FAX 253-835-2609 +perm ddfkiv.com
PERMIT NUMBER
I _ I 5285 _ p> NOV 022017
— — — — TARGET DATE CITY OF FEDERALWAY
COMMUNITY DEVELOPMENT
SITE ADDRESS
` G tiel �� � SUITE/UNIT#
3 1 6. II R-�-e uo, (`C_J(ACIS_
PROJECT VALUATION ZONING ASSESSOR'S TAX/PARCEL#
$ 6o. 00�� a ¶' 2 1. G �I _
TYPE OF PERMIT ❑ BUILDING ❑ PLUMBING ❑ MECHANICAL ❑ DEMOLITION 0 ENGINEERING DZ FIRE PREVENTION
NAME OF PROJECT L4 61 (/t-i ^ )--q I
PROJECT DESCRIPTION Xe ikce Ey Cs 4-IK., I'l c he r it-•• s�/S fft', LA)I`-1`
Detailed description of work to r{ e V a 101 r- C ' -11 k ,? !9 iit r.-+ S7 5f-eit,
he included on this permit only
NAME PRIMARY PHONE
PROPERTY OWNER MAILING ADDRESS E-MAIL
CITY STATE ZIP
---- --- NAME 51.404 1 PHONE //`�{ Q��7•f�
M LING ADITRV Y 1 Ce .. `Ab r3"L - 17
1 l V
CONTRACTOR �d $ + S- ) EMAIL
$$$F be�1.SlfltaI �t-j�.ti',Ibe'
CITY le 4�"f BM
7) ZI7 Q 1 D I FAX �J
-- -- WA STATE CONTRACTOR'S LIC 3 # $}I/z TIox DATE 1^ FEDERAL.4.-Y 1640,-nINESS y1,_ yos 'a�13/.._
NAME PRIMARY PHONE -.- .-
APPLICANT MAILING ADDRESS E-MAIL
r
R CITY STATE ZIP FAX
I
__-- -NAME - -. PRIMARY PHONE
PROJECT CONTACT
MAILING ADDRESS
(The individual to receive and EL
respond to all correspondence
concerning this application) CITY STATE ZIP FAX
NAME
PROJECT FINANCING ❑ OWNER-FINANCED
When ualue is$5,000 or more MAILING ADDRESS,CITY,STATE,ZIP PHONE
(PCW 19.27.095)
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 th' application.
SIGNATURE: DATE 1 V.Z. /17
PRINT NAME: PQ(rQ (V• ' -#9 g,,,C S
liullelin h 100-- January 29.2016 TT Page I of 2 k:AHandouts\Permit Application