15-104424 • •
CITY of PERMIT di l\ TION
Federal Way IVED
SEP 01 2015 1,461/‘
PERMIT NUMBER 15 _ \ 0 4 74- TARGET DATE CITY of FEDERAL WAY
CDs
-- —------- --- SUITE/UNIT#
SITE ADDRESS I
? 16aD– 1 / ''` PL ar(,c) Fed - wa-y WA T V a3 (.o-f# I9
PROJECT VALUATION ZONING ASSESSOR'S TAX/PARCEL 11
$ 61, 8- sc5 ? o b - v / 1 0
TYPE OF PERMIT lJ BUILDING ❑ PLUMBING ❑ MECHANICAL ❑ DEMOLITION ❑ ENGINEERING FIRE PREVENTIOJN
NAME OF PROJECT ir,/71°77)11"– L . .K — Lot 19
f 5izttwfi'( 1 OF 5ph-mete,- 56.1e-011/1-ii pe 1 3 1) , ,h
PROJECT DESCRIPTION -fin
Detailed description of work to to Siden tied
be included on this permit only
NAME –_..... ( 11rL.V LAX...) PRIMARY PHONE
PROPERTY OWNER kiC
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fl-L- - mss} +�-(c "G,wa'V.4�'-c'—
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MAILING. 1 ADDRESS , `""h�{'�1 ay-
CITY
MO— iia—
OilS - Z P]Pj.(l°I _
..���.-,.._..L-s. �_ PHONE
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NAME I..�L� P `�- 4..-C✓ CrF' 3 g�r /' !✓-31
MAILING 4URESS E-MAIL
O j "741 3- dv @t-ame phOtntierMeor
CONTRACTOR STATE LIP FAX
CITY 1AI+ 612' 338 2.53-814-Lv-31 37
WA STATE CONTRACTOR'S LICENSE U EXPIRATION DATE FEDERAL WAY BUSINESS LICENSE II
( .tc..K.P'C. . 3 t<.., 6/ tE /Loa. •-tt-tO3(vtO,.O-51-
NAME PRIMARY PHONE
/ s OL (_Oue A
MAILING ADDRESS E-MAIL
APPLICANT
CITY STATE ZIP FAX
- - PRIMARY PHONE
PROJECT CONTACT NAME y e .r- e Lt ll c,953.---
53.p F„y_.-7..1- 1,-?
(The individual to receive and MAILING ADDRE -T-bun/4)
,W..�,",. inn Y
2 E
respond to all correspondence Poe -Pi �`-' a6t,v0
concerning this application) CITY STATE ZIP FAX
. XV\.,,, (AJA- 11'53''53 8 It
NAME OWNER-FINANCED
PROJECT FINANCING
Required value of$5,000 or more MAILING ADDRESS,CITY,STATE,ZIP PHONE
(RCW 19.27.005)
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 application.
SIGNATURE: s. /-tr, DATE 7/1 //6
PRINT NAME:_ t /' F —
Bulletin#100–January 1,2013 Page 1 of 3 k:AHandouts\Permit Application