13-101363 •
PERM C
��� A.., IT �PPLI ATION
Federal Way RECEIV
ED
MAR 252013
II l
PERMIT NUMBER 3 _ I 0 63 a3-0-
TARGET DATE CITY OF FEDERAL WAY
CDS
SITE ADDRESS SUITE/UNIT#
PROJECT VALUATION ZONING ASSESSOR'S TAX/PARCEL#
X12. 4 g
TYPE OF PERMIT ❑BUILDING 0 PLUMBING ❑MECHANICAL ❑DEMOLITION ❑ ENGINEERING FIRE PREVENTION
NAME OF PROJECT k-.,p__A-t, L.tcly vAYl.e,.o>^,;.-
PROJECT DESCRIPTION
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Detailed description of work to
be included on this permit only
NAM ........,E -. . PRIMARY PHONE
PROPERTY OWNER �'L E"C"U L,,AN.1 v6 tLL 1/4.-c_
MAILIN ADDRESS E-MAIL
3 sr-� 3L.:- G-1 .kL, v S
CITY STATE ZIP
NAIHE�Lv V' -v k- A +v p-�-\0-1P2S`3 - LA v3 3---73 S+2
G ADDRESS E-MAIL
CONTRACTOR /_/')t ) ►12--,C_,\,,14 r'\... - `�
C
`�C-C YN litdo Z p , Llb FAX
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WA STATE CONTRACTOR'S LICENSE# EXPIRATION DATE FEDERAL WAY BUSINESS LICENSE#
Mein VA, X /L'I j-V t I.0 i s._ i_15—
_
NAME
s 6,,,-YtaT� --z --3- L-13
`13-3s-1 2
APPLICANT
MAILING ADDRESS E-MAIL
L (-4 '7
i (/ 6)4-C1104).-- . �jk Lr-)
C 1�1L.F.-M}a 4STAV' Z ,1, ,, FAX
.... .. N l-• .- -- "l
..! PRIMARY PHONE,
PROJECT CONTACT \�()-IQ‘1 t S (-I C�.- 2_0-1 j 2-S3 �' L'I93" 7' ')'2-
(The individual to receive and I'mG D ` E-MAIL
respond to all correspondence � � --'^ + i1-
concerning this application) CITYSTATE ZIP FAX
-----1-C-21 Ce wki)••• IiJI'3 9 Cs•—t 6 1-
NAME
PROJECT FINANCING 0 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
ail 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: DATE 1)2. .3
•
PRINT NAME: �+V1--,-70 �cil-,n-`
Bulletin#100—January 1,2013 Page 1 of 3 k:\Handouts\PermitApplication