16-105418 ayPERMIT APPLICATION
Federal y l PERMIT CENTER+33325 8th Avenue Sou,, se, 1V 003-6325
1 (� 253-835-2607 +FAX 253-835-2609+permitcente cicl of e er way.com
F7:-,
NOV 10 2016
PERMIT NUMBER / _ - _54-I g _ TARGET DATE CITY OF FEDERAL WAY
CDS
SITE ADDRESS _�� 1/e 5 SUITE/U O O
PROJECT VALUATION ZONING ASSESSOR'S TAX/PARCEL#
$ -Z SD 9 c _ 00 5 O
TYPE OF PERMIT ❑ BUILDING ❑ PLUMBING ❑ MECHANICAL ❑ DEMOLITION ❑ ENGINEERING 1Hi FIRE PREVENTION
NAME OF PROJECT fecie✓01`l Ucty'f Io c or U C'/ :4±c 6-J. C-Q A-1"es✓
PROJECT DESCRIPTION IeL 4 6x, sfil {5�p/ d�f'ecf�%✓5 4.1-6{ 0o d p0w �
C
Detailed description of work to Lj 1/ cK A O I I TCCel 1 %od- d e✓r t e¢• .se- rte
be included on this permit only
� PRIMARY PHONE
NAME 54- /�A n C....;‘'5 )'-\\p 5 c 'fry(
PROPERTY OWNER MAILING ADDRESS E-MAIL
CITY STATE ZIP
.
NAME _ - l _--__ __-__. -- PHONE
CONTRACTOR MAILIN ODDREfK
O 7F� 7v).
•/ Ell Iare(41 t j ( €V r'Q4 ,c'
CITY Seatf, ft, J STg4, ZIis ATIl. FAX
WA STATE CONTRACTOR'S LICENSE# EXPIRATIONIDATE FEDERAL WAY BUSINESS LICENSE#
NAME - PRIMARY PHONE -- -_-®
GfaMAC.
APPLICANT MAILING ADDRESS E-MAIL
CITY STATE ZIP FAX
,
NAME -- PRIMARY_- PH&8NE --_-._
PROJECT CONTACT YO(� F4- -s e....0 6 J ( —� 3 J
(The individual to receive and MAILING ADDRESS &m',
respond to all correspondence e("O(csi I s4 i‘.4,'` g ii 6a►
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 city, including its officers and employees, upon the accuracy of the
information supplied to the city as a part of this a lication. I
SIGNATURE: 96,Akt9 Mit DATE (i' U I/
W
PRINT NAME: ti Ali CO yk,...0(1-zBulletin#100—January 29,2016 v Page I of 2 k:AHandouts\Permit Application