12-100015 i
o-'
- 1000 (
CITY OF 1011AE PERMIT SJMFEI ,
� PFederal W �,:,O t
COMMUNITY DEVELOPMENT SaE�ESTSElli5 A LICATION
253-835-2607*FAX 253-83.5-2609
www.cituofederalwau.corn
DERALATY C FE
JAN' 0 3 2012
CDS
SITE ADDRESS / ,FaOF ' A L WAY
tefg
PROJECT VALUATION ZONING ASSESSOR'S TAX/PARCEL#
$ /J - 7 7 a 6 LI F 0 - o ( 0
TYPE OF PERMIT BUILDING ❑ PLUMBING ❑ MECHANICAL
D DEMOLITION 0 ENGINEERING V FIRE PREVENTION
NAME OF PROJECT I
(Tenant Name/Homeowner Last Name) /' 144- / \ f/y
PROJECT DESCRIPTION gcid1licu `;- �o ry'r//o4-t/" c..1) i StA((t/r ceeJ-ecd-ci�
Detailed description of work to (r, n--e S(c.>r. „yr.
!'�Ca.,
be included on this permit only
�-1 ,{ /
PROPERTY OWNER NAME ,� if J t' /J Pte/�4+i t! `r/y��� - / PRIMARY PHONE
( l ri{1 j het a it
MAILING ADDRESS 76.-V 67/( /.� 17 E-MAIL
CITY �� STATE/J ..!!\ZIP
/`�Xe/i"/ (y k/4 77,70.
NAME PHONE
5fsq/Py aJy Moto.
CONTRACTOR
MAKING ADDRESS 2-76D ;lc s is 4 7q„Z.*
E-MAIL
CITY STATE ZIP FAX
��llP�ar wq .:or
WA STATE CONTRACTOR'S LICENSE# EXPIRATION DATE FEDERAL WAY BUSINESS LICENSE# _ "e k?
.77
NAME ` -C,/s? / PHONE
APPLICANT MAILINGADDRESSRESS �haz / 1 c 4' 2.,-,/ a C1.2E-MAIL
CITY / STATE ZIP FAX
{l6 0/1. kq lgCroJ-`
PROJECT CONTACT NAME PHONE
(The individual to receive and e£,�E?cc4
respond to all correspondence MAILING ADDRESS ®� E-MAIL
concerning this application) ��� �Cc t'^'G! e .
CITY vol. STATE ZIP
4,4 G Of— FAX
ALTERNATE CONTACTNAME
/ .6-0--1 'PH'...2.1=7- 7--P c; E-MAIL
PROJECT FINANCING NAME
0 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 ofthis application.
SIGNATURE: -�,6/-C/�ell� DATE VV)- /
PRINT NAME: /(--(4'/Y A"'t C
Bulletin#100—January 1,2011 Page 1 of 3 k:\Handouts\Permit Application