15-105358ORECEIVEDPERMITWPPLICATION
cnr OF 'A
Federal Way
OCT 2 0 2015
j� OFF E FIWAY
PERMIT NUMBER - I v 3 - ffor
— IF
TARGET DATE /
SITE ADDRESSSUITE/UNIT
#
3 2 ASC Fr 2 � M
PROJECT ALUATION
ZONING
ASS OR'S TAX/PARCEL #
$ ciao -
Z_L Z 0 0 3 3
TYPE OF PERMIT
❑ BUILDING ❑ PLUMBING ❑ MECHANICAL ❑ DEMOLITION ❑ ENGINEERING>Q�IRE PREVENTION
NAME OF PROJECT
int tM 6 V 1t d 1 J0,eO
PROJECT DESCRIPTION
Detailed description of work to
be included on this permit only
'e.-; it r Q �AAt
a %OC7 iL
PROPERTY OWNER
NAMEff
SCK( A/IoJ
PRIMARY PHONE
MAILING ADDRESS
v2 5, D-1-1 S'T
E-MAIL
—
CITY
-i,-*c C=
STATE I
ZIP
�} (5
_
NAME
a ;A " r +e C .
PHONE
253 -q? -(,---2290
MAILING ADDRESS I
2-7nl -70-_" 'V � i=
E-KAIL
CONTRACTOR
CITY
-rkev"VM'
STATE
ZIP
1942 -IF
FAX
2!;3°i22-6/.So
WA STATE CONTRACTOR'S LICENSE #
EXPIRATION DATE
FEDERAL WAY BUSINESS LICENSE #
C F
NAME
/I'9'fk+tt �S C o✓l
PRIMARY PHONE
APPLICANT
MAILING ADDRESS
E-MAIL
CITY
STATE
ZIP
FAX
PROJECT CONTACT
NAME`
AI) N, �aCG�
PRIMARY PHONE
(The individual to receive and
respond to all correspondence
MAILING ADDRESS
&MAIL
CI'T'Y
STATE
ZIP
FAX
concerning this application)
PROJECT FINANCING
NAME
OWNER -FINANCED
Required value of $5,000 or more
(RC W T 9.27.095)
MAILING ADDRESS, 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 t ci art of this application.
SIGNATURE: DATE /G -19 -1 S-
PRINT NAME: �o \Jo -C LGA
Bulletin #100 -January 1, 2013 Page 1 of 3 k:\Iandouts\Permit Application