14-104580 • 40
cnr of A PERMIT 4PP R TION
Federal Way
5 SEP 0 8 2014
t
PERMIT NUMBER 14 - 10 4- F 0 F QTY OF FEDERAL WAY
— -- — — TARGET De
CDS
SITE ADDRESS ��/} i� SUITE/UNIT S
PR
$ itef113 CO VALUATION ZONING ASSESSO TA$/PARC a. z-/- q_ 2. 3
TYPE OF PERMIT 0 BUILDING 0 PLUMBING 0
MECHANICAL 0 DEMOLITION 0 ENGINEERING VIRE PREVENTION
NAME OF PROJECTJ� J //i� lp /
PROJECT DESCRIPTION `'' l �� St,C� /N 'e
Detailed description of work to 1 ZNiCjA/3v 4- Ilirr
be included on this permit only
NAME PRONE
,, /�
PROPERTY OWNER //v 1 (Jrr s P PRM--, 1)CLJ•'�v 1 7Z
I a ADDRESS i
/ I.0 ' _�' / An / / /s ' . A
CITY
NAM ZIP
NAME PHoxE
42/4�j, �77� /�C� ��15 x/32�LSo
x HESS 2�� E-MAIL
CONTRACTOR ion .�(.i f /Lr(l/t�i'r/ eced re/►'
50}90T bt-11 73(-S1 25 2zzo
WA/v $CONTRALICENSE EXPIRATION
DATE FED WAY BUSINESS LICENSE tl
/ 77) /l 07 / //c
FAKE , /L� PRIMARY PHONE
„ _(L fie f!J/ -t 7Ci7 V IJILJ /25£.aZ 7Z O
APPLICANT ADDRESS E-MAIL
C k�30 _a 7 f,YLGeil. Ore
STATE ZIPCACI4C6i-E `�'L..�257 FAX �03 223
NAME ('ly�� 1lL�N�/,J/ PHONE
PROJECT CONTACT (.6674t.r+ P 25 JNE --Z7�5
(The individual to receive and
MAILING AD M E:TJ/J E tJ
respond to all correspondence PO nth'61717/ne/r�'jde
concerning this application) CITY STint �r /up ATE �l1 ,,,-5, FAX
/��//l2 2230
NAME ,A �f�f `T Y
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 h• -. Iess the City of Federal Way as to any claim(including costs,expenses,and attorneys'fees incurred in
the investigation and de - -of such claim),which may be made by any person,including the undersigned,and filed against the city,
but only where such • aim s-- out of the reliance of the city, including its officers and employees, upon the accuracy of the
information supplied • th-ci - • -a this application.
fSIGNATURE: (.t DATE
PRINT NAME: C-)17 91' ^Y? aD 4,file-
Bulletin#100–January 1,2013 Page 1 of 3 , 10Handouts\Permit Application