14-102451 •
C 4F RecelvED
PERMIT APPLICATION
Federal Way MAY 2 7 2014
PERMIT NUMBER ''
CITY OF FEDERAL WAY ,
. 5` -
TARGET DATE
SITE ADDRESS SUITE/UNIT#
3201$ re/( /lye S na
PROJECT VALUATION ZONING ASSESSOR'S TAX/PARCEL#
$
9i 7 3a, eta c4.,ng.0 ! G Z / o Y - ? o 2.. 5
TYPE OF PERMIT ❑ BUILDING ❑ PLUMBING ❑ MECHANICAL ❑ DEMOLITION ❑ ENGINEERING X1 FIRE PREVENTION
NAME OF PROJECT (,4 WM Fe,/ Cl[i� 't` �?�/ei^fi�n 72
PROJECT DESCRIPTION (Nati de\ cc 7 (5-pnIn l�GC� ISO �6Cda - '
Detailed description of work to L✓ ,C L(S a l er S"
be included on this permit only
NAME a PRIMARY PHONE
o./
PROPERTY OWNER (4 w yt �ll4 to,' Cf,j,."Gf WIC-,SW-S'666
MAILING ADDRESS
CITY,
Ch ftk SWT ZI7 01 „2,5 ^� �`
NAME PHONE
R'- C '5/ -v 5 zS 3 - t8' L6 S'/
MAILING ADDRESS E-MAIL �,,,
CONTRACTOR
1146 S'c t' E a 01.4 r S",*10�.f;'.-Y.�„
CITY STATE ZIP FAX
7OkCakv r,✓,¢ 182 (/ 2S3 9 1-6 2-31'0
` A fig cs 3`O LICENSE# EXPIRATION DATE / 37RAL AY BUSINESS ewat$sc(=.1=,
, ,8L
N/AME f O n/�'�_�,� � ` L- PRIMARY PHONE
G(Yrl t� 4th tp✓I,n/wL -
APPLICANT MAILING ADDRESS E-MAIL
CITY STATE ZIP FAX
NAME PRIMARY PHONE
PROJECT CONTACT J01,141 �t_i-i,v- , -4JQ
2 c 3 7-44$ 26 f q
(The individual to receive and MAILING ADDRESS E-MAIL
respond to all correspondence So. -S e. 4 ���,' Cp4- Jotih rt9f~"7`4(4;e•rQ,.,
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 to the city as a part of this application.
712 y
SIGNATURE: ' DATE
PRINT NAME: JO. n ^" erT" d`
Bulletin#100-January 1,2013 Page 1 of 3 k:AHandouts\Permit Application