10-103711/o,5
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Federal Way
FPERMIT SF MF CO ME EL PL DE ENI
Fe
C0NT
253-835-2607- lAX 253-835-2609ES AP P LI CAT I O N
Pr-CEIVED
www.citudrederalway.com
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SITE ADDRESS
W� r user Wc,.QTTY OF FE DER Al WAY
SUITE/UNIT ZONING 'ASSESSOR'S TAX/PARCEL # - 6tue7 0
-if 5,', v' 1 a 7' ,•:, " �: C ,� - �� � �'� a se 1 � £ f/yy. � � �" � i x k ,� Zc �R
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NAME PROJECT
Co
or
(Tenant or Homeowner Name)
❑ BUILDING ❑ PLUMBING ❑ MECHANICAL
TYPE OF PERAUT
❑ DEMOLITION ❑ ELECTRICAL ❑ ENGINEERING FIRE PREVENTION
1 \Y
PROJECT DESCRIPTION
Detailed description of work to
be included on this permit only
NAME - PRIMARY PHONE
PROPERTY OWNER
0%) 4S- 0 ^G9
MAH,ING ADDRESS, CITY. STATE. ZIP E -MAH.
Y "
❑ CONTRACTOR APFIfICANT ❑ PROJECT CONTACT
OWNER IS ALSO:
PRDdARY PHONE
( O 1 -
MAILING ADDRESS, CITY, STATE. ZIP
? X \ (�9062.
FAX
( 8 - 9-(d�
Y ONTRACTOR
WA STATE CONTRACTOR'S LIICENSE #
EXPIItATION DATE
FEDERAL WAY BUSINESS LICENSE #
\(
jA9 U-
I
PRIMARY PHONE
APPLICANT
Y v% YpjnNec1O
( A)-
MAH.ING ADDRESS, CITY, STATE, ZIP
FAX
\\\ C�r� eog
( - 9S
PROJECT CONTACT
NAMEPRIpMARY
V'�
PHONE
(lire individual to receive and
CIO,
( Z ) p N - Tlokoq
MAILING ADDRESS, CITY, STATE, ZIP
FAX
respond to all correspondence
concerning this application)
(' 19k 96qg
ALTERNATE CON'T'ACT NAME:
PRIMARY PHONE
E --MCAD.
( -
S\C.a ecmto h
PROJECT FINANCING
NAM
OWNER -FINANCED
Requiredfor projects with
MAD,ING ADDRESS, CITY, STATE, ZIP
PRIMARY PHONE
value of $5, 000 or more
(RCW 19.27.095)
( 1 _
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
Wormation supplied a city as a part of this plication.
Q 2
SIGNATURE: DATE an Jo
PRINT NAME:
Bulletin #100 -January 1, 2010 Page 1 of 4 k:\Handouts\Permit Application
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