13-103751 CT'OF •• PERMI'1eAPPLICATION
Federal Way RECEIVED
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PERMIT NUMBER I l _ 10 ✓ 51 _ P' AUG 262013
— TARGET DATE CITYOF F((EnnDCCER,AL WAY
SITE ADDRESS SUITE/ P§#
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PROJECT VALUATION ZONING ASSESSOR'S TAR/P
_ o 0 ) .7._
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TYPE OF PERMIT 0 BUILDING 0 PLUMBING 0 MECHANICAL 0 DEMOLITION 0 ENGINEERING KFIRE PREVENTION
NAME OF PROJECT /12- e -' -1c -" /I I G
PROJECT DESCRIPTION /'�
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Detailed description of work to YY �Y'7�/ITi!/G�l
be included on this permit only
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NAME PRIMARY PHONE
PROPERTY OWNER /`k4f l/ CS
MAILING ADDRESS E-MAIL
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CITY STATE ZIP
NAME S A � Ce,o fael---..r3.3-3.3- Y'
MAILINGLINGADDRESS / E-VI. /�
CONTRACTOR v��f `S �� /( CSS fCr Lt�"wiz
CITY AID ZIP FAX
1 ‘4041
WA STATE CONTRACTOR'S LICENSE# EXPIRATION DATE FEDERAL WAY BUSINESS LICENSE#
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NAME PRIMARY PHONE
it/Y --- ago-. yi
APPLICANT MAI�S"�ADDRESSLING j 4014: MSLel / ri
CITY STATE ZIP FAX 'r i
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NAI ��/� PRIMARY PHONE x,5,1/
PROJECT CONTACT ({+L[ti zeit ke„ 'Y�' WD •�Sa7�
(The individual to receive and MAILING DRESS E-
respond to all correspondence i'1 i i t 4e SC ' ��r
concerning this application) cI ST E ZIP FAX
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NAME
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 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 arty 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 t city as a part of this application. • p
SIGNATURE: / DATE O 41-6' /v
PRINT NAME: 'II.: _' 4%/e..—
Bulletin
#100-January 1,2013 Page 1 of 3 k:\Handouts\Permit Application