14-102480 S •
CITY OF A IERMIT APPLICATION
Federal Way RIVED
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MAY 292014
PERMIT NUMBER 14 _ l _
__ _ TARGET DATE CITY OF FEDERAL WAY
SITE ADDRESS SUITE/UNIcPS
3C1_,3 ( &f AVS S
PROJECT ZONING ASSESSO� AX/PARCEL#� O � - � � O
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TYPE OF PERMIT ❑ BUILDING ❑ PLUMBING ECHANICAL ❑ DEMOLITION ❑ ENGINEERING FIRE PREVENTION
NAME OF PROJECT rx, ttp P+-5 •
PROJECT DESCRIPTION � 1 `((� Afli- PI �� S �l
Detailed description of work to ,
be included on this permit only
NAME PRIMARY PHONE
PROPERTY OWNER
MAILING ADDRESS E-MAIL
CITY STATEZIPZIP
r e� i�y�2-caw w`J ( (HO3 6s7- ?-t$2.
LIjADDRESS E- L �ll
CONTRACTOR " -' �`��� t V @, 1,01111 I ci�P�i #r C14- 3".
C TY STATE I ZIP FAX L.c5-41
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WA STATE C TRACTOR'S LICENSE# EXPIRATION DATE FEDERAL WAY BUSINESS LICENSE#
U.WJ t IM.M t 0 y cP M ,- S / / t> .t.5--
NAMp PRIMARY PHONE
„DA nAR
APPLICANT MAILING ADDRESS E-MAIL
CITY STATE ZIP FAX
NAM '�,A I PRIM Y PHONE
PROJECT CONTACT I l.Jet'l 421 ��D -110 5-
(The individual to receive and MAILING ADDS E-MAIL
respond to all correspondence I1+1A-e-__ Crrt.i q6.1(561o61 Au:i' Co Y"`
concerning this application) CITY STATE ZIP FAX
NAME
PROJECT FINANCING ❑ 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 e city as a part of this application. GG�`` L,.�.
SIGNATURE: ` DATE /l/�u I I 1
PRINT NAME: 'r2XI5
Bulletin#100-January 1,2013 Page 1 of 3 k:\Handouts\Permit Application