11-104649 AIL
41_ - _ I ® k L 1
CITY OFdm. •PERMIT MF CO ME PL DE EN FP
Federal Way T
COMMUNITY DEVELOPMENT SERVICES A P P L I C D ��� 1
253 www.607•FAX ahvau.5-2609 i� AovD
www.citUoIfederalwaU�com �f
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SITE ADDRESS CO 7 / ��` '-- p laigy � ��WAY �TE/UNIT# `
3
$ PROJECT VALUATlurn ZONING ASSESSOR'S TAX/PARCCPS ) I ) / / /
� 9g 69 0 - 0 � oo
TYPE OF PERMIT ❑ BUILDING ❑ PLUMBING El MECHANICAL
❑ DEMOLITION ❑ ENGINEERING IRE PREVENTION
NAME OF PROJECT(Tenant Name/Homeowner Last Name)
1=7-a,10 ( c:1_ c5Y'-.c; Os
PROJECT DESCRIPTION ,
Detailed description of work to F ( v-f ' 1 M'V'A S ie.-I__ Com„_ -�,--wl/L
be included on this permit only tirtEvt •-
NAME / , / eo �``,'`/V PRIMARY PHONE
PROPERTY OWNER //�_ a ! /A�� S 0 L
l /NG / f ADDRESS 6/a er I� /U G E-MAIL ....
CITY K/Jr/k l ^ STATEJJ- ZIPS Y O 3 3 /,�
NAME / ! PHONE
le E�/ C_/ �/�' �' r t� /3 (a( Vo
MAILING ADDRESS f ,�/ r\^N/..� E-MAIL ::: :,,,1/CONTRACTOR a J `► 5 C I a/4s hiiik_ - "V ,e re Yet,d I ie �Y; c .Ce w,
CITY1:45.....E 3TIr'� 4ZI ( • Ic- (e ) 413 -g o
WA STATE CONTRA/CTOR'S LICENSE#/ / EXPIRATION DATE - DERAL WAY BUSINESS LICENSE#
/ c„..p
/
NAMECA1241*, PHONE
r
APPLICANT MAILING ADDRESS E-MAIL
CITY STATE ZIP FAX
PROJECT CONTACT /� '! � l
(The individual to receive and N 'C Aft,V'4)�"`— ' r C ..A vl s f e 1 r L''�• P�UC/2/ i 3 r£ / bo
respond to all correspondence MAILING ADDRESS E- L
concerning this application)
CITY STATE ZIP FAX
ALTERNATE CONTACT NAME: PHONE E-MAIL
PROJECT FINANCING NAMEEl OWNER-FINANCED
Required value of$5,000 or more
(RCW 19.27.095) LING ADDRESS,CITY,STATE,ZIP PHO •
di
I certify under penalty of p- 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 •. curacy o the
information supplied to the city as a part of this application.
SIGNATURE: / / / a...." ,.'�
l 7 //
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Bulletin#100–January 1,2011 Page 1 of 3 k:\Handouts\Permit Application