12-100938 WI
/ D ® �/ 3g
arydF
A.
4s� 9 SF MF CO ME PL DE EN' FP
Federal Way 2,- 20,2 PERMIT
COMMUNITY DEVELOPMENT SERVICES�pFEDE 'PLI CATI 0 N `6$�
253-835-2607•FAX 253-8 E (OF Cos
uu'u.cltuoflederalma:g emt `VS
SITE ADDRESS SUITE/UNIT#
3 3 W 0D Qt eve Aerc.1 .,/ ljc (9)0
PROJECT VALUATION ZONING ASSESSOR'S TAX/PARCEL# l
$ ! 1 11'15°6 9 a (9 5 d ( - 0 0 to 0
TYPE OF PERMIT ❑ BUILDING ❑ PLUMBING ❑ MECHANICAL
❑ DEMOLITION ❑ ENGINEERING 'FIRE PREVENTION
NAME OF PROJECT ///
(Tenant Name/Homeowner Last Namel Got(dm 54
ole- LLC_ - &neil `���hxS }}} mnto 44-01
PROJECT DESCRIPTION rent:, ' ti -. Rel 0(6 te- ± e)(cs 1((15 sold& c(c eci-or,
Detailed description of work to Acid `j n e er sm re claelec,40r5 in /)e4_1 o? %ce g?aces 2�
be included on this permit only Cror,
n recon ce room, c( neo Forn S-kel�e tt\ Coc\receneQ
Coon,'
NAME l J LLC. PRIMARY PHONE
PROPERTY OWNER GoICI U I ane ?fro?er -e,5 LLC•
MAILING
15RESSS S.
S1-(V . Sul e A E-MAIL
CI�j d eGI G` STATE ZIIP•
e ( kI A CIS 003 t� /��
NAME \QSh i n5+n AICrm Tic , PHON - 30 '' `.^�S�
MAILING ADDRESS E-MAIL
MADl AC �L(l )
CONTRACTOR I 953 S. cd'< U^ '4- Mmti � n& dC_ .. t
m
CITY T FX
^Ce ll, c, t1,4 "0k,-20 •
1 2 I`f
WAS T ONT CTOR'S L LENS # EXPIRATION DATE FEDERAL WAY BUSINESS LICENSE#
I ,a - 3 10 /03 X13 ao-00-kok69q-6oi3L.
NAME vi PHONE
CiS k n c-bn P I Grm .1-AC... . 00(9 '32`6-
APPLICANT MAILING ADDRESS E-MAIL 6Vi`S
1953 3 ( <5O \ �j 51- . kb is 111„r�.l'�t.,N(ak?a Ili&a M. (MN
CITY �1_ I e $T\�E ZIP/�y l L4� T6b-3,9a-?V I l
PROJECT CONTACT NAME �(^i�t/ /� Mc7-1
\F• ]1/` PHO) r c
(The individual to receive and 1' I C`r r` c I W a( n oV ��-3 V
respond to all correspondence MAILING IADDRE_SS (` `�l'!, MMAIL
concerning this application) 1 a 1S 3 c7. M�f�� �� ` 111�C.1I&,(1 leaks i n, CCI NI'Cf
CITY.`ci 1 le ,SdcTE ZIP �� Jai-Sag•t7914
ALTERNATE CONTACT NAME: 11('` PHONE E-MAIL
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.
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
'� C /'oofthis application.
�r����
SIGNATURE: / ,t l �!i��'/ - ��' DATE 0- ^
/�
PRINT NAME: / (i('j( /l4 - 7.yG/i)
Bulletin#100—January I,2011 Page I of 3 k:AHandouts\Permit Application