11-104923 / (f) (7/.? 2 3
IL, -
CITY UP AciervEe PERMIT SF MF CO ME PL DE E FP
Fed
COMMUNITY DEVELOPMENT 3 zC 11 APPLICATION
253-835-2607•FAX 253-p 9 I
www.atyogederaltua.com
SITE LID
OF FEDERAL W AY
SUITE/UNIT#
3 L I o0 — +''' ,Ave_ S
PROJECT VALUATION ZONING ASSESSOR'S TAX/PARCEL#
6 'ZOO. O O 1 3 Z / g 0 - D 0 2- 0
TYPE OF PERMIT ❑ BUILDING ElPLUMBING ❑ MECHANICAL
❑ DEMOLITION ❑ ENGINEERING f FIRE PREVENTION
NAME OF PROJECTf_ E F D 0 `dS
(Tenant Name/Homeowner Last Name) `�C`
PROJECT DESCRIPTION `T e"in O.A .* :i:-m e f o U e --17:3, - ,'k-'e Ct I/
Gi if-47P?
Detailed description of work to
be included on this permit only
NAME PRIMARY PHONE
PROPERTY OWNER
KRS �o ld�40s L L C
MAILING ADDRESS E-MAIL
'7o3 Si 35o ' c
STATE -"
CITY kJ4 ZIP
edefa l LV9 g 0 2 3
NAME
_ PHONE ,.
Merl di eta Se.cu e--l 1kCl ec-iv-; c c. 253--(03,--• • , 2
MAILING ADDRESS /� / E-MAIL / i
CONTRACTOR •` 0 NI?1' t ) sj GO (I 1 IAA 5e(_t-v-i'-i b 1 Z.
CITY Li STATE Z FAX
ne..4-�' 4)4- B®tf% 253 4)?2 039 6
WA FTATE CONTRACTOR'S LICENSE# EXPIRATION DATE FEDERAL WAY BUSINESS LICENSE#
file KIels copra S e5iyz / i/Z 06-/oo/ c -oo--$1._
NAMEPHONE
5GL-v , ct5 c,1?O J
APPLICANT MAILING ADDRESS E-MAIL
CITY STATE ZIP FAX
PROJECT CONTACT NAMES , PHONE
(The individual to receive and C � �(s 2,S 3 3 7
respond to all correspondence MAILING ADDRESS
concerning this application) Po 6a x 7 I� ' JCLo'T(y E-MAIL6yllee'ldi&-7J .ceiil---/1", b/2.
CITY STATE ZIP FAX
IA)/4'" r'7 vd Y 2— Zr3 (05G 0 316
ALTERNATE CONTACT NAME: PHONEE-MAIL
Ss tvei1 t�I,'M a,i- 2S?ea3 f'/ei2 s...a,/te, .e.,.,'c�,`a.�s,t.d..-.4,
PROJECT FINANCING NAME0 OWNER-FINANCED
Required value of$5,000 or more /�V( 'ynJ�
IRCW 19.27.095) MAII.ING KESS,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: .3).6� R —
DATE Z12 I I
PRINT NAME: F!)reil L-e H4 teiti 5
Bulletin#100—January 1,2011 Page 1 of 3 k:\Handouts\Permit Application