14-105380 •
CITY OF PERMITtPPLICATION
Federal Way RECEIVED
I� - 0 3 o _ FP OCT 152014
PERMIT NUMBER `
TARGET DATE CITY OF FCCEDE A 1 WAY
SITE ADDRESS SUITE/IIAIP#
35-7-DS Il.0A
$
PROJECT TION ZONING ASSESSOR'S TAX/PARCEL# l D L7 _ /
2 Z o
TYPE OF PERMIT ❑ BUILDING 0 PLUMBING" 0 MECHANICAL 0 DEMOLITION ❑ ENGINEERING 'N'IRE PREVENTION
NAME OF PROJECT �J�,,"f . /0 f-t-1 --1yy�,yy
e6i3Yl/J�✓lS F6� t( cf J '1 v-k -r- ��l ICPS�m
PROJECT DESCRIPTION J J
Detailed description of work to
be included on this permit only
N E PRIMARY PHONE
PROPERTY OWNER rl� LL(_
MAILING ADDRESS E-MAIL
CITY STATE ZIP
NAME PHONE
l,f 11l 1 r►414e L YYLe Ll .v►;c.csl , ►tic. 2S .dalo "c1-7
LING ADDRESS LIS7-
4c,�
CONTRACTOR O `S 1�� ��O l�=�YnC�� ' ��'`
CI STATE ZIP FAX
WA STATE CO RACTOR'S LICENSE# EXPIRATION DATE FEDERAL WAY BUSINESS LICENSE#
UNLL01144.1-0GCv ►"� 5 / I3 / 15
NAME C PRIMARY PHONE
APPLICANT MAILING DRES E-MAIL
CITY STATE ZIP FAX
NAME PRIMARY PHONE
PROJECT CONTACT �CL.&LC_
(The individual to receive and MAILING ADDRESS E-MAIL
respond to all correspondence
concerning this application) CITY STATE ZIP FAX
NAMEOWNER-FINANCED
PROJECT FINANCING LU�T
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 de a of such claim), which may be made by any person, including the undersigned, and filed against the city,
but only where such aim arises out of the reliance of the city, including its officers and employees, upon the accuracy of the
information supplied o the/city as a of this application.
SIGNATURE: 6 F DATE 101 15 17 y
PRINT NAME: C ret.151 t
Bulletin#100-January 1,2013 Page 1 of 3 k:\Handouts\Permit Application