11-100765 _ t_ - i O._ 0 (0
Federal Way PERMIT CO ME PL DE EN FP
COMMUNITY DEVELOPMENT SERVICES I
Vii
253-835-2607•FAX 253-835-2609 A P P L I C A'T
www.cityoffederalwaq.com
FEB 2 5 2011
SITE ADDRESS f-f k,-W Cirwra �j� FERAL WAY SUITE/UNIT#
sif 5. 311 qtr-e.e.�. ,'• RIAcf � i-ck.y , °v S
PROJECT VALUATION ZONING ASSESSOR'S TAX/PARCEL#
%f3;'. 0 . a _LO .3 - (1 4 3 $
TYPE OF PERMIT ❑ BUILDING ❑ PLUMBING 0 MECHANICAL
0 DEMOLITION 0 ENGINEERING /FIRE PREVENTION
NAME OF PROJECT
(Tenant Name/Homeowner Last Name)
'3f. l.taftps aiurc
•
PROJECT DESCRIPTION _ g)(—E nct eAvstiNs wetsytea,4 ' �1-De ii ,7 O ,.trE� A 0( .k,• ido_s
Detailed description of work to 1k tA. ctc\I 1r._ 'iyST-=.yr1 tO cf'Jt,Z.k fin r_.6 it,E'86:4sd (fr ",y
be included on this permit only
r(A' `/ Lti 1s1-VI U(via VbrI;l b i-k �n it&�- add 1l-, t1
NAME PRIMARY PHONE
PROPERTY OWNER COnsN)n`i-ir kY1 l,I\i'tNL) 1_044.5 �S-' 'MI, '
MAILING ADDRESSE-MAIL
S 5 , �11h St+
CITY STATE ZIP
f:taeft,l LYi\'/, nMlA/J+; CI Cir.a3 `�
NAME �T,\\l F%1�<_ Si'CtL-oa 17 PHONE d�' ca,- 1 E,RQ
MAILING ADDRESS - E-MAIL
CONTRACTOR 117 `SLI iw% _ �L N1�h a sN,.�l-1. �
CITY STATE ZIP FAX
rec-.k. A �i8'+aq s3- (-1 ("„ - Dib
WA STATE CONTRACTOR'S LICENSE# EXPIRATION DATE FEDERAL WAY BUSINESS LICENSE#
yi'11.11-{•F-3(c:,Oii / a / i a iy-Z7- ^ 5--x-,64_
NAME i 1 PHONE
APPLICANT MAILING ADDRESS E-MAIL ,
CITY - STATE ZIP FAX
t l / % t l I r
PROJECT CONTACT NAME PHONE
U'' "S��iV a
(The individual to receive and � ��3
respond to all correspondence I3 � ��(
MAILING ADDRESS E-MAIL
concerning this application) 1'l�ir 51-1-dc �v Q [ �� fie_ SM1a1 i✓ �sl'III/�U'1>:rCi 03/'r1
CITY STATE ZIP FAX
1✓c,,tam LA ri&LI3.44 js5- c - .50
ALTERNATE CONTACT NAME: PHONE E-MAIL
(1,-,o c60 C 153-380-FR{: be n4_6. soca-Ike, (J't( \
PROJECT FINANCING NAME
0 OWNER-FINANCED
Required value of$5,000 or more
(RCW 19.27.095) MAILING ADDRESS,CITY,STATE,ZIP PHONE
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.
SIGNATURE:
(711/ sti--) ii,„--i DATE I SJ l
PRINT NAME: v .scs -c. Z 4)N-111--L
Bulletin#100—April 14,2010 Page 1 of 3 k:\I-{andouts\Permit Applicatioi