18-100888 Ark PERMIT APPLICATION
CITY Ofii� w
PERMIT CENTER+R� th + Federal Way,WA 98003-6325
Federal Way 253-835-2607 + 5-2 +permitcenter@cityoffederalway.com
� � _ FEB 262018 � �
PERMIT NUMBER 1
I OV CIN OF Fff®EE /
COMMUNITY DEVELOPMENT
SITE ADDRESS ��``" / SUITE/UNIT#
V
PROJECTVALUATION ZONING '
���
""
ASSESSOR'S TAX/PARCEL#
TYPE OF PERMIT ❑ BUILDING ❑ PLUMBING ❑ MECHANICAL ❑ DEMOLITION 0 ENGINEERING_ FIRE PREVENTION
NAME OF PROJECT \brCu n' E?i" 0 1n� .� �Ca l C
PROJECT DESCRIPTION t
Detailed description of work to 'O f.)\ CJS ,l E n o \/v t `l 1)r
be included on this permit only •\.\rk \,� ,y (' 4�Lyyl
NAME v�• 1 W PRIMARY PHONE
PROPERTY OWNER . ,047 \ � (\i � �
MAI G ADDR SS E-MAIL
juad
5CITY STAT ZI
sae ��l U WA- beca
N.wEMAIILING�ADDREr ADDRESS �., E-MAIL
fk\AQCONTRACTOR `1A , ` S �� p J y
CI�vJ�-�' ZI�ra
k.� l FAX
S
EXPIRA
ION DATE FEDERAL WAY
35113 C,1WAATATE
� O IJ SI ®-1 / TI /�C / • 3�WI�d6 LICENSE
NAME PRIMARY PHONE
ULA L0-1 ) a e.r�.
APPLICANT MAILING ADDR E-MAIL
1-14l II stead ly � tfa--c (A,
tirs 3yo p1 FAX
NAME CAS ,- PRIMARY PHONE
PROJECT CONTACT f 1 � v J C& CCVVI S
(The individual to receive and MAILING ADDRESS E-MAIL
respond to all correspondence
concerning this application) CITY STATE ZIP FAX
NAME
PROJECT FINANCING 0 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 arty 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: ^e^,- DATE( 19,"' (1,
C
PRINT NAME: Ck
Bulletin#100—January 29,2016 Page 1 of 2 k:Mandouts\Permit Application