15-104825 S
CITY OF PERMIT APPLICATION
Federal Way RECEIVED
_ e zs - SEP 2 2 2015
PERMIT NUMBER 15 O
-
TARGET DATE 1"YTV 11P FEDERAL WAY
SITE ADDRESS SUITE/UNIjT'if S
320) d-1 32 Av Sri. /20
PROJECT VALUATION ZONING ASSESSOR'S TAX/PARCEL#
(` a i 6 LA ? Z - coCil o z a)
TYPE OF PERMIT ❑ BUILDING ❑ PLUMBING ❑ MECHANICAL ❑ DEMOLITION ❑ ENGINEERING til,FIRE PREVENTION
NAME OF PROJECT i 1 r 1 \A S CU
PROJECT DESCRIPTION F At.A0.4‘.4+ . (b b i t'1" � cn e b E 1(J LES"
Detailed description of work to
be included on this permit only
NAME PRIMARY PHONE
PROPERTY OWNER
MAILING ADDRESS E-MAIL
CITY STATE ZIP
NAME 4 PHONE
MAILIING ADDRESS -1 EMAIL
CONTRACTOR .e174• ) /3 �7" TF 10
CITYA 14 gt4 4 STA- TE ZI 60 t FAX
WA STA7 CONTRACTOR'S LICENSE# EXPIRATION DATE FEDERAL WAY BUSINESS LICENSE#
14 giN%.=wi : 77 i;w l / /3 / s /
NAMEPRIMARY PHONE
Q
M
APPLICANT MAILING ADDRESS E-MAIL
CITY STATE I ZIP FAX
-
NAMEPRIMARY PHONE ,7/ �y
PROJECT CONTACT J 1''�'ALL.7J �f4MAJd 2'5 -- i � -` 20'8
The individual to receive and MAILING ADDRESS / E-MA�ILL, �/
respond to all correspondence r � ( i J frl oua /elm/E./ge (r44^
concerning this application) CITY /� SATE/ zlg.� FAX �y�
AILIaae-v l 1�31ti I aOC .S-3 G moi'"2413
NAME
PROJECT FINANCING Ej OWNER-FINANCED
Required value of$5,000 or more MAILING ADDRESS,CITY,STATE,ZIP PHONE
(RCW 1 9.27.095)
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 applicat' n. J//3
d _DATE
L is 1' S
SIGNATURE: (L;7
PRINT NAME: -.51+(-6-44 LEO: &A J
Bulletin#100—January 1,2013 Page 1 of 3 k:AHandouts\Permit Application