13-105559 k
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1 A PERMIT APP �+ it -
CITY
Fderal Way 1
i
fry DEC 32013
i PER IT NUMBER _ ! �../ ,-5 5 q _ FP CITY OF 1 3 201 WAY
I - TARGET DATE
SITE ADDRESS CDS
BDITE/UNIT#
PROJECT VALUATION ZONING ASSESSOR'S TAX/PARCEL i
$ 23O(2 0 C0 2 - l 5 `I 7 0 - C) 0 0
TYPE OF PERMIT 0 BUILDING 0 PLUMBING D MECHANICAL 0 DEMOLITION 0 ENGINE.ENIN0)FIRE PREVENT:ON
NAME OF PROJECT A i ,
PROJECT DESCRIPTION A IN b '
Detailed description of work to ,? .. ')be t� ,\ ?�O 0/1A,
be included on this permit only )
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Allq
6i PROPERTY OWNER C ST4t ,/��,i1p \^»
PRIMARY PRONE
MAILING AD RESS ll� -r '
E-MAIL
);{7Wt i1
k A1t� (�
NAME
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-TY(0p [♦. -� T �j g.1—t� 4 �tt - 3
r� �` -+j 4� , K'} E-MAIL
CONTRACTOR w t( �wrV�j � P�`�."""it�y��C 0 fin".
CI
Y �le "- mas � PAX 1�
WA STATE CONTRACTOR'S LICENSE# EXPIRATION DATE PLOERAL WAY BUSINESS LICENSE#
- / /
NAME PRIMARY PHONE
APPLICANT MAILING ADDRESS EMAIL
CITY SPATE I ZIP FAX
t�� A PSIS/NARY PHO?CE._. .. _
PROJECT CONTACfi ��"r t1,""11 i. J J
(The individual to receive and M o ADDRESS B MAIL t "1 113
respond to all correspondence 1 t "I � . �Y-
Concerning this application) nn ! STA 1 zg� \ P
AX
NAME W�
PROJECT FINANCING 0 OWNER-FINANCED
Required value of$5,000 or?note MAILING ADDRESS,CITY,STATE,ZIP
(4CW 79.27.095) PHONE
I certify under penalty of perjury that I ate 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 cot,..?.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 ap lication.
SIGNATURE: DATE J�, e,e 13 ,20y3
PRINT NAME: Care( rj N 1'[i VV.rr
Bulletin#100-January 1,2013 Page 1 of 3 k:\Fi unduuts\Permit Application
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