17-106045 `, PERMIT APPLICATION
CITY OF
PERMIT
p CENTER+ 33325 8th Avenue South +Federal Way,WA 98003-6325
Federal Way253-835-2607 + FAX 253-835-2609 + permitcenter@cityoffederalway.com
I initial'
PERMIT NUMBER i _ 1 0 v _ FP
— — — TARGET DATE DEC 2 0 2017
SITE ADDRESS
CITY I6III�E/IT # AY
54 24 o c� , -%J e_ S ---c.the_ -QJ W Q / 'J COMM u�mr DEVELOPMENT
PROJECT VALUATION ZONING ASSESSOR'S TAX/PAI CEL#
$ 9000. o0 g 3 5- F a 0 _ 0 C (Q O
TYPE OF PERMIT 0 BUILDING 0 PLUMBING 0 MECHANICAL 0 DEMOLITION 0 ENGINEERING M'r'IRE PREVENTION
NAME OF PROJECT D i',....._ C-K-s<,,I,
PROJECT DESCRIPTION j)
Detailed description of work to (IA.e n� v r S 1 --ut ('6 M'_ g_ p `tbsx._
be included on this permit only /
NAME PRIMARY PHONE
b11vty Cl--i 13
PROPERTY OWNER MAILING ADDRESS Kt E-MAIL
eJle.r 1 \O sty STATEviA ZIP ��po3
NAMEIv e v.s W A7 1 r-"--cr-y y l et, C PH`. L, 4-To 4 6 2 0
MAILING� ADDRESS _l! / E-MAIL j�, /,.-, /� _ _
CONTRACTOR '` 5 f�e 1t u1 Jar► a.�i�6`�WVI `1d .
CITY-• ZIPtv
Nil Lc' FAX
WA STATE CONTRACTOR'S LICENSE# EXPIRATION DATE FEDERAL WAY BUSINESS LICENSE#
pC:w W /vela-I-0(9 Btu of /02.0 / /'
NAME - PRIMARY PHONE
A- 012-1 A-0 3A-D L,TAr
MAILING ADDRESS . E-MAIL 71 Carel COI
APPLICANT t �o S� 210 v.1 pc 13 J r/' • 3� crA-- 2i-
CITYZ"1-"•: �1--\
STATE ZIP ^ 8 g_® FAX
NAME V" �t \f`/ \1 PRIMARY PHONE
PROJECT CONTACT
(The individual to receive and MAILING ADDRESS E-MAIL
respond to all correspondence
concerning this application) CITY STATE ZIP FAX
NAME
PROJECT FINANCING ❑ OWNER-FINANCED
When value is$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 ci , including its officers and employees, upon the accuracy of the
information supplied to the cit gs_apart-ofthis-application. I
SIGNATURE: l DATE /. .• Q ` 2 o /1-
PRINT NAME: -DLk- / Pt-N .a PI-DELI T
Bulletin#100-January 29,2016 Page 1 of 2 k:\Handouts\Permit Application