11-100343FederalAUFCEIV 'ERMIT
COMMU35-260 -PAX 25 -8 SERVICES
253-835-2607• FAX 253-835-2609 J A N 2 6 APPLICATION
www. cif votrederahuay. com
rTTY QE FEDERAL WAY
I L - 1 0 0 --? 4-3
MF CO ME PL DE EN FP
SITE ADDRESS
! /E5,
SUITE/UNIT N
2 P 2f
PROJECT VALUATION
$ 4200
ZONING
ASSESSOR'S TAR/PARCEL N
S 4 3-zf- 2 O
2 L
TYPE OF PERMIT
❑ BUILDING ❑ PLUMBING ❑ MECHANICAL
❑ DEMOLITION ❑ ENGINEERING IRE PREVENTION
NAME OF PROJECT
(Tenant Name/Homeoumer Last Name)
(V\
PROJECT DESCRIPTION
Detailed description of work to
LW h l-4-71
be included on this permit only
PROPERTY OWNER
NAME
PRIMARY PHONE
MAILING ADDRESS
E-MAIL
CITY
STATE
ZIP
9r
NAME
-"at,
PHONE
Zoe 11411-
G ADDRESS
b (
E-MAIL r
CONTRACTOR
CITYw
STA E
FAX 7 to
WA STATE CONTRACTOR'S LICENSE N
Rim
EXPIRATION DATE
8
FEDERAL WAY BUSINESS LICENSE M
t*b
i Aft
NAME llxz�
PHONE
APPLICANT
MAILING ADDRESS
E-MAIL
CITY STATE ZIP
FAX
PROJECT CONTACT
NAM
l• ftp' C6IVIN 4&
PHONE PHONE
(The individual to receive and
{.V -
MAILING ADDRESS
E-MAIL
respond to all correspondence
concerning this application)
CITY
STATE
ZIP
FAX
ALTERNATE CONTACT NAME:
PHONE
E-MAIL
PROJECT FINANCING
NAME
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 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 ci as apart of this application.
01S
SIGNATURE: DATE�/�
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PRINT NAME: 42ot me +�6L VIJ&L --
Bulletin # 100 – April 14, 2010 Pagel of 3 k: l-landoutsTermit Application