09-102566 __ rr )
RF ,,,,,,.. h . ,, , 40.,... 4111► r
ctn.OF A JUL a'+` PERMIT SF MF CO ME EL PL DE E, FP
Federal Way /\ /��
COMMUNITY DEVELOPMENT FA 253-8 5 260 3 E L��'��'TT ■ A 1 I O N -,..."..-1-
253-835
-
253 835 2607•FAX 253-835-2609V�j F1r �1,t Y V Li
SITE ADDRESS
31-4-7 61+1\ Aec vsOvi re' dei/ 04/ W4` c/(Q30
/
SUITET# ZONING ASSESSOR'S TAX/PAL M L ® 0 / 5
:3� .. ..,.. . i. ....<-. ;s,1,; <-44,,,W.,,'''''.61"
, PROJECT �.. ,"
NAME OF PROJECT
(Tenant or Homeowner Name) P IV1'6 raGacki, Fpm=1-ur 3 1..)S0 i?it nJ''c e
❑BUILDING ❑ PLUMBING ❑ MECHANICAL
TYPE OF PERMIT
❑ DEMOLITION Cl ELECTRICAL ❑ ENGINEERING ($°FIRE PREVENTION
PROJECT DESCRIPTION �X r417.4%).6. F34-1,-- ,,ot L/A n ival SYS 1
Detailed description of work to
be included on this permit only
els-`1`3
--1-gPEO, LEr 5 ..
NAME PRIMARY PHONE
PROPERTY OWNER ( ) -
MAILING ADDRESS,CITY,STATE,ZIP E-MAIL
OWNER IS ALSO: El CONTRACTOR 0 APPLICANT ❑ PROJECT CONTACT
NAME - ..._ .._. PRIMARY PHONE
�(11JJ 4-1TL S`f's"ceiv1s w- s'r (z53 ) --33 -k2,4..8,
Vl. CONTRACTOR MAILING ADDRESS,CITY,STATE,ZIP G 3U4") FAX
Vi 2956 (- Qc4.3Ta 2000 1.)- 113C.,PACIFIZ , uJ.A-, (ZS3 )-73S - e\13
I., ).\ WA STATE CONTRACTOR'S LICENSE# EXPIRATION DATE FEDERAL WAY BUSINESS LICENSE b
F112E L�� - �ssc.+.j O /k6 /► I (9-20--c�oeoi- -OO_8L
NAME PRIMARY PHONE
Plc
APPLICANT l e- 5-7'S-re viis kJ e&-i- (2.53 )13;3 - 1 2U g
MAILING ADDRESS,CITY,STATE,ZIP C'gtAJ) FAX
1O( FnolvTA -e (20A0 I , Poo1CaFlc, W^. ( ZS3 )?3S - 0 113
PROJECT CONTACT NAME PRIMARY PHONE
(The individual to receive and FSU(O P CT tuts t--- (2 C 3 yip p - 1()t y
respond to all correspondence MAILING ADDRESS,CITY,STATE,ZIP el 304) FAX
concerning this application) ZO 6 F7\OH}i q - kCA-0 Li 4(, PAC1 Pic, ,u4-, ('25-7 )135 - v 1 1 3
ALTERNATE CONTACT NAME: PRIMARY PHONE E-MAIL
1--h2.E1J 6UTLer\— C2-$'3 )&33 - I 8 F1tRFAcPeFateStS s,uTtovl
PROJECT FINANCING NAME
El OWNER-FINANCED
Required for projects with
value of$5,000 or more MAILING ADDRESS,CITY,STATE,ZIP PRIMARY PHONE
iRCW 19.27.0951
( )
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.
Ifurther 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 . . part oft application.
SIGNATURE: DATE 1—7
' I 0 C
PRINT NAME: ,� Fe ft3.J v Pei-fall jf,�
Bulletin#100-4/21/2009 Page 1 of 4 k:\Handouts\Permit Application