14-101523 CITY OF PERMIT�APPLICA. ON
Federal Way "
4 1 i APR 0 3 2014
PERMIT NUMBER ( \ F� TARGET DATE CITY OF FEDERAL WAY
CUS
SITE ADDRESS SUITE/UNIT#
3\6 23 kit S 21$I l\ ViPt
PROJECT VALUATION ZONING ASSESSOR'S TAX/PARCEL#
$ CO 1 _ _ _
TYPE OF PERMIT ❑ BUILDING ❑ PLUMBING ❑ MECHANICAL ❑ DEMOLITION ❑ ENGINEERING ,Iq FIRE PREVENTION
NAME OF PROJECT
• 411S''Srik-3a -Mk‘00\-\<-\--Za\VINS AtNICCK -ktc"
PROJECT DESCRIPTION
Detailed description of work to
be included on this permit only
NAME PRIMARY PHONE
PROPERTY OWNER
MAILING ADDRESS E-MAIL
CITY STATE ZIP
NAM ` j`�`(0R � 9\\ PHONE
MAIL'INNGDRES .-. ( � l E-MAIL
CONTRACTOR , ( to
CITY ZIP 7 FAX
FEDERAL
LICENSE#
W `�� K CS KAC L-. EXPIRATION^�'' DATE 2 1C:3" 1 C k sJ C f 3L-
NAME � ;!. r_��� PRIMARY PHONE
APPLICANT MAILING ADDRESS J t E-MAIL
CITY STATE ZIP FAX
PROJECT CONTACT NAME V Vt. c , Z \ \ PI N 1"
(The individual to receive and MAILING ADDRESS E-MAIL
respond to all correspondence
concerning this application) CITY STATE ZIP FAX
NAME
PROJECT FINANCING Li 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 suPPli to the city as a part of this application.
SIGNATURE: '\N\A CXThUk9 DATE _ 1�
PRINT NAME: ��( 0 1�/ �J� ‘C
Bulletin#100-January 1,2013 Page 1 of 3 k:\Handouts\Permit Application