15-101621 . -SUBMITTED
- W IR 03 PERMITS PPLICATION
Feera ay 2015
CITY OF FEDERAL WAY
CDS/
PERMIT NUMBER 5
_ C D i /�f A I _ TARGET DATE
SITE ADDRESS 12 0 I llllll/// SUITE/UNIT#
So,.)-td, 336 . h 51- Fcc.)e-rod (ik1e&y WA
PROJECT VALUATION ZONING ASSESSOR'S TAX/PARCEL#
aLl; 53700 L� c w c 1,
a,� c _
TYPE OF PERMIT 0 BUILDING 0 PLUMBING ❑ MECHANICAL El DEMOLITION 0 ENGINEERING cgr FIRE PREVENTION
NAME OF PROJECT .Ki H3 Cor ne_r. Moil-) a m k
PROJECT DESCRIPTION 1 (+
Detailed description of work to U rde,f5r0 Unca t';rt, 5uft)y i I ne—S 'r0 )C, b,.Aci 1 t1)) Q.} 'tkc-. 0C; )3 s Corr.-T-
be included on this permit only /y) /
rYI NAME �/ 6 1 PRIMARY PHONE
PROPERTY OWNER 911 H Co (1C.{' LLL E'/S e 1J 3 - 9`J s i
MAILING ADDRESS E-MAIL
6O9OO N! nth 61 e.e,$ Su, i-c. )DOO juvoa r.)e.cicvc,.v0.1ots.(,onn
CITY d)CVe STATE ZIP
°J� u..)A 91300 -1
NAME PHONE
L.90�/ e�, �n�c,rr;ae / tn �- PS3 37-1 W)0MAILING ADDRESS 1 E-MAIL
20 13o>C 3-8 7 q 9 S4Wlc
tbel)0yd,.n. .r/onM
),44,4,GO
CONTRACTOR � ) �i Q/^�r�^�
CITY i....-..tri
�f....6 v"�' STATE� ZIP'..'. /0 003 FAX as3 a3' 010 3
WA STATECONTRACTOR'S LICENSE# EXPIRATION DATE FEDERAL WAY BUSINESS LICENSE#
L�.o 1OI I.a3$o1 " / /s i5 RD-00- 1O 1)38-00-t3L_
NAME PRIMARY PHONE
3&.me. c.b C_or t rc,�c.%o[-
APPLICANT MAILING ADDRESS E-MAIL
CITY STATE ZIP FAX
NAME LlPRIMARY PHONE
PROJECT CONTACT Wer r2
�w✓marr\ CLloyd � e-rrior'aw )^(.•) 953 3737L/ CC 9a
(The individual to receive and MAILING ADDRESS / EMAIL
respond to all correspondence Janne °` (-emir..c.i Y` Sid-,.t-�7Q))oe^�u'Pri)f.�ink•(Ow,
concerning this application) CITY STATE ZIP FAX
253 333 0103
NAME
PROJECT FINANCING r��` OWNER-FINANCED
Required value of$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 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.
.4SIGNATURE: / DATE 1-4./Z1/2.0/PRINT NAME: 5te.tle, a.tln\a.l� Lloyd yof �:n ikrprl,k.,)6 rri(..
Bulletin#100—January 1,2013 Page 1 of 3 k:AHandouts\Permit Application