12-103824 .� Er� f_tt- 10_ 3_ q-a2-- Y
CITY OF "ECEIV PERMIT SF MF CO ME PL DE EN FP
Federal Way r
COMMUNITY DEVELOPMENT SERVICI G 1 •7 n/ i"�P P LI CAT I O N
253-835-2607•FAX 253-835-2609
www.cituoffederalway.com WAY
CIT(OF Fg:RA
SITE ADDRESS tts¢040 .
1002 S . 312 1-15T.,FFDS Al. V/11-`i I \T../A 94003
PROJECT VALUATION ZONING ASSESSOR'S TAX/PARCEL S
$ 42, 69`I-• 05 RM %O0 4- 1 4 Z 6 0 - O 0 op
TYPE OF PERMIT ❑BUILDING 0 PLUMBING 0 MECHANICAL
0 DEMOLITION 0 ENGINEERING '.FIRE PREVENTION
NAME OF PROJECT
(Tenant Name/Homeowner Last Name) _P F S 11]E, V I LLAL&E CC)N DO►.n't41 v Ists.
PROJECT DESCRIPTION F1Ct= AL�!}1CM I JslP1LI'1ATION FO - '78 CONDC�MIN�VM
Detailed description of work to U N VT 5 , , J
be included on this permit only -..1 d i' / .
I
NAME is IZUCE C N kfik 1" PRIMARY PHONE
PROPERTY OWNER .1./KO-TOC C)L P Ro PER.-r't M ANP+6S MF,.ry 11 b-r%') %'3,5- 503'2,
MAILING ADDRESS E-MAIL
I O W Pri-SON ST• NOA.Th\ D(,vc-Et1:PMSovT1-1Lb0‘
CITY STATE ZIP FAA
E NV i c1"11/4•lJ w c>; 9'?,022 Cum 802.-2_00-2-
NAME
oomsN AI-L W I . ., SLE.cTRcc. PID(X 6) 935-61 bo
MAILING ADDRESS /MOIL
CONTRACTOR 3034- 5W cA-iNz Y.sro\I.,N 5-1" JeRemi At4 VALI-wli.E.ELfccF4C,CON.
CITY
5 epsTT 1�c \n, p1 ZIP
i3 2k F
0-0(3)93S 4,229117
WA STATE CONTRACTOR'S LICENSE S EXPIRATION DATE FEDERAL WAY BUSINESS LICENSE d
AL.tA.1INN t=.9b1G1C i i 2.8 /2(i ZO-rt- t02359 -00-5L
PRONE
N EREN.1pN L3RAJNSTI n); AL-0419ct {,2UF,) 935- 6Ib0
utnAPPLICANT MAILING ADDRESS E-MAIL
3534- SW CVAPSR .ES'fOWN .SY 5.Z.t:MIA p,A.NFIltteew.,cmc.coM
CITY STATE ZIP FAX
S C ATI-1—F 'ger frt q 911 47 (.7.- ; 51s-4-z8o
PROJECT CONTACT
NAME PHONE
(The individual to receive and s A M� A 5 A 17c1-1CPQ
respond to all correspondence MAILING ADDRESS E-MAIL
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
(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 o reliance of the city, including its officers and employees, upon the accuracy of the
information supplied to the :4'. as a .' o • - -- n. ! /
Vr
SIGNATURE: DATE ` �l 2
PRINT N• „ - J Cel ')t'L. 4(AWLS j-C-J k
Bulletin#100-January 1,2011 Page 1 of 3 k:\Handouts\Permit Application