10-104398- OVA (PERMIT
Fedeeal Way
CONW1211TY DEVELOPMENIEC
253-835-2607- FXX 253-1 6 E14"LICATION
QrT 1 8 2010
-4a-Y3 j&)
WMF CO ME PL EN Fl?
SITE ADDRESS
SUITE/UNIT #
PROJECT VAIMITION
$ C[)9NING
ASSESSOR'S TAX/PARCEL #
TYPE OF PERMIT
0 BUILDING 0 PLUMBING 0 MECHANICAL
0 DEMOLITION 0 ENGINEERING FIRE PREVENTION
NAME OF PROJECT
-
(Tenant Name/Homeowner Last Name)
(3L.'-(' t,) 0 C-5
PROJECT DESCRIPTION
, kk y\c"-', 1c, r� e- A\
Detailed description of work to
be included on this permit only
PROPERTY OWNER
NAME• PRIMARY PHONE
n V- cnlalj) OZ -5
MAILING ADDRESS
c> I
E-MAIL
ZIP
NAME
F L", -N C"
PHONE
'20 ko -c) 2�
NWLING ADDRESS
N- 0
B-BL41L
C hc,- -
CONTRACTOR
CITY
STATE
FAX
00
0
W TATEOCtNTRACTOR'S LICENSE # EXPIRATION DATE
L4 ClAk I �) caz 0 A
FEDERAL WAY BUSINESS LICENSE #
NAME
PHONE
MAILMG ADDRESS
E-MAIL
APPLICANT
CITY STATE ZIP
FAX
PROJECT CONTACT
(The individual to receive and
N
PHONE
MAIIJNG ADDRESS
S--N-t- --I 'S Co -,AC C -i CA VC,
E-MAIL
respond to all correspondence
concerning this application)
CITY
STATE
ZIP
FAX
ALTERNATE CONTACT NAME: PHONE
E-MAIL
PROJECT FINANCING
NAME
OWNER -FINANCED
I
Required value of $5, 000 or more
MAILING ADDRESS, CITY, STATE, ZIP
---- - -]
PHONE
(RCW 19.27.095)
I certify under penalty of perjury that r am the property owner or authorized agent of the property owner. r certify that to the best
of my knowledge, the information submitted in support of this permit application is true and correct. r ceft(& that r will comply with
all applicable City of Federal Way regulations pertaining to the work authorized by the issuance of a permit. r 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.
rj4rther 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 such claim), which may be made by any person, including the undersigned, and filed against the city,
but only where such clai s out of the reliance of the city, including its officers and employees, upon the accuracy of the
information supplied to e I part of this application.
SIGNATURE:, DATE
PRINT NAME:
Bulletin #100 — April 14, 2010 Page 1 of 3 k:\Handouts\Per-nrit Application