13-104643 �\ O
•arra. PERMIT APPT:tM, A JE N
Fetal
In 2 OCT 21 2013
PSH1aT NUMBER I _ f `� / _
TARGET DATE CITY OF FEDERAL WAY
NTE ADDRESS j Wariti0RX
n00 QCT s- - r t-V4--‘Af -I _,. .N II
VALUATION. I ONIN.c� i
•
4.rz.vG •u j - '.. S C� t1 e V.
TYPE OF PERMIT 0 BUILDING 0 PLUMBING 0 MECHANICAL 0 DEMOLITION 0 ENGINEERING L IRE PREVENTION
NAME OF PROJECT A c7 ee�.e4i e-� J 4 s._6Oq A,r- c
111
PROJECT DESCRIPTION RC-Q u £��M 1 (ii:.
l LVTtly rtJ,r'�'f�`R-0 L..t. es 1 7 t`i14
E).te led da _a tion Vj-wwk j r-Y'',11 i
be included on tis puri.ante
NAME PRDttHY PHONE
PROPERTY OWNER
MARANO ADDRESS • E•ttAIL
Cur I STATE 1 SIP
fAMS t
R
IC 00 ( < u 131tLLC t
WAILING ADDRESS aztAlc
CONTRACTOR •:.4 u V. y 1II
CITY ';' STATE. ZIP FAX
$cameos r ERP f wATION DATE FEDERALWAY mums I.ICNESO4
--•__... .
APPLICANT ' MAIWROADDRESS E-MAIL
CITY STATE ZIP FAX
NAME PJt1NARY PHONE
PROJECT CONTACT
tie individual to receive and MAILWO ADDRESS EMAIL
nnnrl to ar mr o...so ip._ I I
11 caniexrnng this appifrxftIon) COTE i STATE !zip j FAX
NAMEi _ _ - _— _
PROJECT FINANCING p OWNER-FINANCED
Regnired mane of$5,000 or more MINING ADDRESS.CITY.STATE,ZIP PHONE ,
(RCW 19.27.095)
I certify under penalty of perjury that I em the property owner or authorized agent of t&8 property owner.I certify that to the beat
of my kmowladge,the information submitted in auppwt of this permit application is true and correct.Icer ilq that!will comply with
all applicabl a[.Ybs of lrederat Wan mssslsstt ns neriafrsrne to the work m2hmere y 5r th t "wee or a ws«.!e- r r-a..--fin.[+r.,.*t4e
—_ IRIS __-t .Zvaa -et s'euwer the siwnrra .•Al _ .- -
{
ow-- :� Jri.rnns rcaparnaeaaucg for compaaaee with local, a+lase. or federal laws regulating
caustruciion or smoonrnentai tarps,
i farther agree to hold harmless the City of Federal Way as to any claire(including eztst:.e�grrenses,.and attorneys'.fees:,incurred:in
the Investigation and defense of such claim),which may be made by any person,including the undereignedandf filed the city,
but only wham such claim arises out of the reheat,of the ally, including its gOlcers and employees,upon the aeauacy of the
information supplied to the jetty as a part of this application.it
SIGNATURE: Ibl DATE fa t 711
PRINT NAME; 614A/rY+
Bulletin#100-January 1,2013 Page I of 3 k:\llIndouts\Pe rmit Application
Northwest paperwork Page 2