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13-101570 a oFPERMIPAPPLICA'TION remma APR 0N9 2013 CIT' 9 tU�"^'r WA - ° 1 5 - TARGET DATE CDS SITE ADDRESS SUITE/UNIT# 3 a 75 3a "- Ave S. PROJECT VALUATION ZONING ASSESSOR'S TAX/PARCEL# $ -7 5-0. a© i I 5E1 625 - 00g0 TYPE OF PERMIT ❑ BUILDING ❑ PLUMBING 0 MECHANICAL ❑ DEMOLITION 0 ENGINEERING gr FIRE PREVENTION NAME OF PROJECT 0A-V a T a1 3.1 p(,t&se_ 3 PROJECT DESCRIPTION ae\ocaAioin Q.nc& adlokil'Ove. 04- no - coca. — CA-9 pk IAce Detailed description of work to Ik( _ - _ _ __.. be included on this permit only - NAME I- PPRIMARY PHONE PROPERTY OWNER 1)/ \ at%"c1 g 0- . 73 MAILING ADDRESS E-MAIL 1 Li a.3 �o..<<•;A.. Ave_ 4,)ooa. e 914-c O o1'1 CITY STATE ZIP Tato o. W ctg4Oa•. NAME t $- PHONE C:orvver ‘n-}' �ecknolr,c �eS tial--a7a- naso MAILING ADDRE S* E-MAIL CONTRACTOR 1-15-0 J V J VOCk AVL' S. C Y ST TE ZIP F erti�n et. 4 OS-7 fas-ras 1-4aciq WA STATE CONTRACTOR'S LICENSE# EXPIRATION DATE FEDERAL WAY BUSINESS LICENSE# Cony 6-re 9 B t113 b, NAME PRIMARY PHONE lerrr. �,ry t 4-1, S3 - 73a- 5`q 6 APPLICANT MAILING ADDRESS E-MAIL WSJvc Ave_ S. 91enn•5fA% ,e ctnVt.(1 KAP,con, CIT STATE ZI FAX ev��o►2 v,)a So s NAME t PRIMARY PHONE PROJECT CONTACT G 1eri+ti Sr A_t- QS 3- 73 oZ-S-96 6 (The individual to receive and MAILING ADDRESS E-MAIL respond to all correspondence y5 5�.0. �VC k Aut S , c11�nh•5+ � c�r��cr91 A , Lar+n concerning this application) CITY ` STA ZIP FAX (Q\2Y\,Tom' W)s NAME PROJECT FINANCING D OWNER-FINANCED Required value of$5,000 or more MAILING ADDRESS,CITY,STATE,ZIP PHONE (RCW 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 city/itas a part of this application. SIGNATURE: j� �?•�t��../al G�`�— DATE 4/i3 PRINT NAME: (Mcc�taC Bulletin#100-January 1,2013 Page 1 of 3 k:AHandouts\Permit Applicatior