13-101930 •
w CRY OF PERMITIAPPLI
Federal Way
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2 0 0 MAY 01 2013
PERMIT NUMBER I % _ 1 0 , CI
_ 0 CITY OF FEDERAL WAY
- -
TARGET DATE CDS
SITE ADDRESS SUITE/UNIT 41
g'1so3 9 .6 Ault satkli
PROJECT VALUATION ZONING ASSESSOR'S TAX/PARCEL#
WOO � � a45f - QOSe
TYPE OF PERMIT 0 BUILDING 0 PLUMBING 0 MECHANICALIC0 DEMOLITION 0 ENGINEERING 0#FIRE PREVENTION
NAME OF PROJECT fr cis M ed;a I PGIt/1 11441
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PROJECT DESCRIPTION n eta Detailed description of work to fl�ol i i i et I 1 c,v,
be included on this permit only
NAMEPRIMARY PHONE
PROPERTY OWNER 5-g-, FIrt.441t13 n y;iirl I
MAILING ADDRESS E-MAIL
CITY STATE
Wi- ZIP
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NAME l(t sysI Vf 5 WP PHONE Z- 3 i/ 3 IZq t .
MAILING ADDRESS
CONTRACTOR 20. FYI JJ L° A) ?Ail't) Five sys/e sf�Je c-!M'
CITY STATE ZIP FAX
A . c WA- `Ikre�''1
WA STATE CONT CTOR'S LICENSE EXPIRATION DATE FEDERAL WAY BUSINESS LICENSE#
kill E«- # iS1�&S J:Z ocSLHI 12i 3 r 13
NAMEPRIMARY PHONE
hl Le_ 253- 20Z-7MS-
APPLICANT MAILING ADDRESS E-MAIL
CITY STATE ZIP FAX
NAME PRIMARY PHONE
PROJECT CONTACT rrli 24-3-adz- 70HS
(The individual to receive and MAILING ADDRESS E-MAIL
respond to all correspondence
concerning this application) CITY STATE ZIP FAX
NAME
PROJECT FINANCING 0 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 to e city as part of this application. f
SIGNATURE: DATE - /I 1 13
PRINT NAME: Phi Lt
Bulletin#100-January 1,2013 Page 1 of 3 k:'Handouts\Permit Application