13-105190 1
_I. •
F,rroF l• PERMIT APPLE ,�N
Federal WayL�U`'
�✓/ NOV 19 2013
PERMIT NUMBER _ Lb_ I 0 _ CI1Y OF FEDERAL WAY
L°1 \\ TARGET DATE CDS
SITE ADDRESS SUITE/UNIT#
'47o4 (l FI . 3
PROJECT VALUATION ZONING ASSESSOR'S TAX/PARCEL#
$ c,0-1
TYPE OF PERMIT ❑ BUILDING ❑ PLUMBING ❑ MECHANICAL ❑ DEMOLITION ❑ ENGINEERING :14.FIRE PREVENTION
NAME OF PROJECT YAC) VLA 0 k. _ DEP/T.&L
PROJECT DESCRIPTION Te•oii 0-rt L f"r V v JE hh E Iv-T - F-I I.Ir�
5 f' - Y 1,-F-
Detailed description of work to A bAL La(.. ,-r-E - r ALS S F-D f` WE w Wilt-t_S A_E 3 N3t
be included on this permit only
NAME PRIMARY PHONE
PROPERTY OWNER
MAILING ADDRESS E-MAIL
CITY STATE ZIP
NAME PHONE
-1 Az y "-r iv N w .sem jS3 -`6"703--12.AR
MAILING ADDRESS E-MAIL
CONTRACTOR i012 FV-viJ7hI`iE F-0 J STE r i� 1
CITY 'TY�Lf �t (� 1C'LS1S -4.1MSC -st Cgl
STATE ZIP FAX
MCA F—I `_ wA '")8o47
WA STATE CONTRACTOR'S LICENSE# EXPIRATION DATE FEDERAL WAY BUSINESS LICENSE#
i 1 ; '14zs 6 I2/ 3 i / t3 t'�-f3-e ms 14-o� 0.7
NAME .. .. PRIMARY PHONE
`JAPA.E AS Est)
APPLICANT MAILING ADDRESS E-MAIL
CITY STATE ZIP FAX
NAME PRIMARY PHONE
PROJECT CONTACT -Pe}C I?-o0 DAVIS
(The individual to receive and MAILING ADDRESS E-MAIL
respond to all correspondence SAN"(s.: A A 60 v-€
concerning this application) CITY STATE ZIP FAX
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 ofperjury 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 suc claim),which may be made by arty person,including the undersigned,and filed against the city,
but only where such claim arises J ut of the reliance of the city, including its officers and employees, upon the accuracy of the
information supplied to the city a a part of this application.
SIGNATURE: DATE i 0 CO 3
PRINT NAME: T/}Epa,›cJ b,Avi S
Bulletin#100-January 1,2013 Page 1 of 3 101-Iandouts\Perniit Application