11-104580 A. • ii - tc45 O
CITY OF PERMIT SF MF CO ME PL DE EN FP
Federal Way
COMMUNITY
25 8355-2609 FAX 253-835 2 09SERVICES
APPLICATION ! 1d
wwwcit yotferleraiway.com
NOV 152
SITE ADDRESS
1 00 ��, ccs. CITY OF FATAL WAY
CDS
PROJECT VALUATION ZONING ASSESSOR'S TAX/PARCEL#
$ kk , 2Z0C' 13 i I a - 0 0 2 0
TYPE OF PERMIT
0 BUILDING 0 PLUMBING 0 MECHANICAL
-_...w._.
0 DEMOLITION 0 ENGINEERING CAIRE PREVENTION--,
NAME OF PROJECT -�
(Tenant Name/Homeowner Last Name) E FCC 1),S
PROJECT DESCRIPTION I A./3"7-4L(V /C/ (,,' PC.:- �il/K.t- .,e J /4.1 0 Fl=7 c-C.description of work to S C'C el IVCD DE-Y 'PC/.ID i'J7'J //./ C-00tt i 41.1,Dbe included on this permit only
r Jac',,
Z. 2•
NAME PRIMARY PHONE
PROPERTY OWNER iz,S hict-D 1ti/Cl L . C—
MAILING ADDRESS E-MAIL
CITY STATE ZIP
NAME PHONE
ill gc- C� CC��S i ZuC i iOt-J 1t� C 253 2 --1222
MAILING ADDRESS E-MAIL I
CONTRACTOR /42-'55 S. 2 OU 4-h kc
CITY STATE ZIP FAX
r T /4 '1c3z253 42,�2 ' 32-33-
WA STATE CONTRACTOR'S LICENSE# EXPIRATION DATE FEDERAL WAY BUSINESS LICENSE#
D X. / /
NAME PHONE
'PE-1-e.C VEL-0 1) 253'A� 2-�2.Z -1>"-------22
-E3 MAILING ADDRESS EMAIL D� 7 A D O @,
e 55 5- c,411 ,cai_CHCR-CON:S1-RxtC,YiUN .0°NI
CITY STATE ZIP FAX
Kt/4 T irk)/4 9 SC93 Z 253° a2 1-'11-1
PROJECTCONTACT NAME PHONE
(The individual to receive and ?�.•T C,IZ. D E(<6 XI D v
respond to all correspondence MAILING ADDRESS E-MAIL
concerning this application)
CITY STATE ZIP FAX
ALTERNATE CONTACT NAME: PHONE E-MAIL
4164 . thL ', -A 25a•a'42• 222
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 applications 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 city as a part of this applicat'on.
SIGNATURE: ��� DATE //-/6----/(
PRINT NAME: g/G/.4 f9 ( //yA4-1LQ
Bulletin#100-April 14,2010 Page 1 of 3 k:\Handouts\Permit Application