10-101648 • — /oI6L/ `
` -A. ECEIV/ED PERMIT SF MF CO ME PL DE Ely' FP
Federal Ways
CO 53-836 DEVELOPMENT FAX 253-8 5ERvic�' R 2 3 24P P LI CAT I O N
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CITY OF FEDERAL WAY
SITE ADDRESS CDS SUITE/UNIT#
3 2 12 3 2. d 1r UE S . fired'1 '14)3- / T r
PROJECT VALUATION ZONIN% "� ASSESSOR'S TAX/PARCEL I - V
$
321/ % / >� / 4 5 — —
5-6
TYPE OF PERMIT ❑ BUILDING IDPLUMBING 0 MECHANICAL
❑ DEMOLITION ❑ ENGINEERING FIRE PREVENTION
NAME OF PROJECT
(Tenant Name/Homeowner Last Name) ]/�,.1 � �L (� - 4��i'l 5�� 1 1.. jy1 t%:
PROJECT DESCRIPTION DD ,t-l�.l,,,,�- /Si-robe _�4- �r i'I!'�x S f b
Detailed description of work to •1 '€44/ /ri4 IC-z/`I''G'dl
be included on this permit only
NAME PRIMARY PHONE a
PROPERTY OWNER view /hieusir - e/ c�i+'!S 2S-3-12 V 7D6y
MAIL ADDRESS E-MAIL
cos' 3rd 14ve
CITY STATE ZIP
�e /e 'v� ai(i 3y
NAME czvl PHONE
uar/4-t-,,-(- 'ec /, J 4 e's �i7 -2 72- Z 25-6'
G CONTRACTOR 7 J v ADDRESSE-MAIL
SSTATE QA
CITY e Y'I •••`;� ZIP R aP FAX
WA STATE CONTRACTOR'S LICENSE# G7EXPIRATION DATE FEDERAL WAY BUSINESS LICENSE#
Cry. /cie r"L 98Y 62 /2c,z. Ze -/pz1_3i et
NAME PHONE
gOk, 361,- 23g- V?9Z
MAILING ADDRESS E-MAIL
APPLICANT 1/S-0 / /,; ,flee_ S. 1(01,0_4 .cisg H
C STATE ZIP FAX
PROJECT CONTACT NAMEPHONE
(The individual to receive and v h 61; 1-7 S.< 36o-7 3
respond to all correspondence MAILING ADDRESS 7 /� 'may,' /� e
conceming this application) 5---a v1 #4' Sive' dIAIL
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CITY9 STATE ZIP es,2 FAX l 441
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ALTERNATE CONTACT NAME: PHONE E-MAIL
PROJECT FINANCING NAME
0 OWNER-FINANCED
Required value of$5,000 or more
(RCW 19.27.095) MAILING ADDRESS,CITY,STATE,ZIP PHONE
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 reli.nc. of the city, including its officers and employees, upon the accuracy of the
information supplied to the ci•, • a .a of this .*p ation.
DATE _
SIGNATURE: / '2 3 7 6`0
PRINT NAME: "L4'
Bulletin#100-April 14,2010 Page 1 of 3 k:\Handouts\Permit Application