11-100534 41/4 w_ 1 - I_ 00 �- 5
CITY OF
4114
PERMIT SF MF CO ME PL DE E FP
Federal Wad/
.pt
COMMUNITY DEVELOP, s 9PLI CAT I O N
253-835-2607•FAX 32 3 9 `i
w w w.cttyoffederaiway.com
FEB 0 9 :‘-f la°
SITE ADDRESS SUITE/UNIT#
3 a/a — so• reel r„lis ',For) / / 10
PROJECT VALUATION ZONING ASSESSOR'S TAX/PARCEL#
$ ora/3oo " 2 I 5-- _ d o b
TYPE OF PERMIT ❑ BUILDING ❑ PLUMBING ❑ MECHANICAL ��"
111 DEMOLITION ❑ ENGINEERING FIRE PREVENTION ,tib 4l1bP,m Sys.
NAME OF PROJECT n
(Tenant Name/Homeowner Last Name) 120 cx i 6/1J/1/s �+ AM at
PROJECT DESCRIPTION ADO veither.c1srettooes el- S a®des To -reAhtuir r4 cG. /Y1voi fy F�yc,P
Detailed description of work to 1 A c .3T VP;GC. �✓44` pp��ppNLw?T. /4 AO /4posi& X)144.t/Slot t
be included on this permit only / /
foe SEtc,i$GS. helerCeemit,dt/I 'eirAc aCi4Ta e.r/.53..SMaG ders
NAME PRIMARY PHONE
PROPERTY OWNER 3 a/a?5 of)vR 4/ 44 4--
MAILING
MAILING ADDRESS E-MAIL
02f251/5 Z?"JAYe- So. Aare-,24 • 7 p.00 sittn-.scwlt cJoe•cowa.
CITY STATE ZIP
He.vr 1,44 . 9P03.2- 1933-�Z'•9
NAME PHONE
Covj/l )Ai �4.wv/oy1es,Ld c 42517.t. So
MAILING ADDRESS E-MAIL
CONTRACTOR 4So $44,17kete Ave So• 1f /pp 61.614w4 „),/6 COOkr.. :441..tw.••
CITY STATE ZIP FAX
,heti/o.✓ 804 OW 7 f $-,5/-vs60
WA STATE CONTRACTOR'S LICENSE# EXPIRATION DATE FEDERAL WAY BUSINESS LICENSE#
40A),V4 •4. 919 .640 _ / /8 /dD/.2 os-19- 130-00-64
NAME PHONE
G/ si Ste;i7,/ 1953-.7.3.2•S,412.
APPLICANT MAILING ADDRESS E-MAIL
Sec Cvvl.L' .'A/% .)/ . AOsniG
CITY STATE ZIP FAX
PROJECT CONTACT NAME c' PHONE
(The individual to receive and 6`/BAJA) j. :7/rJ A5 3-7.342-591.--2-
respond to all correspondence MAILING ADDRESS /' E-MAIL
concerning this application) 5e4 &,v fr.VT/NA' A4 v
CITY STATE ZIP FAX
ALTERNATE CONTACT NAME: PHONE E-MAIL 372184.1, fir/ •e Q//
f?10 csii/l - 1955 3811 e cmI,sree; •d''''”'
PROJECT FINANCING NAME
El 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 reliance of the city, including its officers and employees, upon the accuracy of the
information supplied to the a I t of this application.
SIGNATURE: 41DATE 44:9.-4 C/
PRINT NAME: it/it///"/i/
Bulletin#100—January 1,2011 Page 1 of 3 k:A Handouts\Permit Application