13-101569 c, VED p
Federal Way ERMIAppj,jCATjpN
APR 09 2013
CITY FEDERAL I`y /J /�"')
PERMITp NR- V _ p
1 TARGET DATE
SITE ADDRESS
3 7 ' 3d --cfAve- S. SUITE/UNIT#
PROJECT VALUATION J/�- ZONING ASSESSOR'STAX/PARCEL#
$ —
W 011 s.D Q 41 f®%
TYPE OF PERMIT
0 BUILDING 0 PLUMBING 0 MECHANICAL 0 DEMOLITION 0 ENGINEERING
11 NAME OF PROJECT FIRE PREVENTION
,
PROJECT DESCRIPTION Ze,o tci, ari tZrtal • �, (� 8
Detailed description of work to r �-� �'�,, �p r r(. i:cLCct.�tcSdA. �i ,4 (�'aV►L°.e (4‘.be included on this permit only i��" C(:Q fide 1 Gr Tp' a �� O,� T‘d^.
NAME -------- __
PROPERTY OWNER ¶0. .t I PRIMARY PHONE
MAILING++ HADD•ESS 06 - C 6'8 a I "7 3
�t i 3 �t1-�-1 TSL /7't1 E-MAIL \y�
CITY STATE ZIP
0 � '`�'° o L
1 G.C.0 CAO, VJ cam. C 3 q O a.
NAME
CQ 1f\V et-,. A..3 k, 11Ct.ky1Q{L^s te..-, PHONE -
MAILING ADDRESS �a 72 a,23-0
CONTRACTOR
LIS O .S }�vCl{ � S.
ITY Q `
mit... z4P
WA STATE CONTRACTOR'S LICENSE# 5 ' �^ _4
T t,1 13 O EXPIRATION DATE FEDERAL WAY BUSINESS LICENSE#
Ccs R V e l TR
NAME
G ��n� sly. .�� PRIMARY PHONE C_ 1!' _
APPLICANT
MAILING ADDRESS s- l 7 J c(b
LUSO Shc,3(vc(ce S, lin,SrvtiPhe Cowe,
CITY { Q ( ''') a 0011
--- �tV\.VOY} STATE ZIP q 0 0 S. 2
PROJECT CONTACT �/iiiiimil
PRIMARY PHONE
87,
(The individual to receive and MAILING ADDRESS �3 ��6
respond to all correspondence 146-0 S�,j t(( Ave S E-MAIL �7
concerning this application) CITY 91enN•SOA t41A e CC A veey+„1f”, cow,
pS <nfn n STATE ZIP
q16,5-7 lijIIIIIIIIIII
PROJECT FINANCING _
Required value of$5,000 or more 0 OWNER-FINANCED
(RCW 19.27095) 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 of this application.
SIGNATURE: -- 4- �/ g
q�� DATE / /3
PRINT NAME: ,:�tiC/ 4% Aver
Bulletin#100—January 1,2013
Page 1 of 3
k:\Handouts\Permit Application