10-103579A. .�
, ,. Booth 1 6
Federal wa ' (a RERMIT SFS �� FP
�U� g Detailed
COMMUMTYDEVEfA 253-8 SERVICES A CATI
25 latvu)cLtUo eAX253-835-2609 ,ffPubject to attached �+et�tils
www.ciluolTederal_ com
�'1 iD5 1'Y
SITE ADDRESS Date "— q ,
Z10 20 WAY4 k -0A
SUITE/UNIT #
VALU
Q PROJECT®D TION 0
ZONING
ASSESSOR'S T� AR�#
TYPE OF PERMIT
❑ BUILDING ❑ PLUMBING ❑ MECHANICAL
❑ DEMOLITION ❑ ENGINEERING KFIRE PREVENTION
NAME OF PROJECT
(Tenant Name/Homeowner Last Name)
PROJECT DESCRIPTION
C$ L-. � vie t e. -D {4 i�d eo
Detailed description of work to
C` t` [.MP ✓In G
Li
be included on this permit only
PROPERTY OWNER
NAME PRIMARY PHONE
eoCyi R<
MAILING ADDRESS E-MAIL
3 tCi tj E 1310 � � td ' 9-rk -2t--2'
CITY gTXTE
c 1i t 1 �,Lw-
SujA
] f�
NAME PHONE
Cr CtrrRt Seems v 1 Czo6Y3e IZGS
MAIIdNG ADDRESS E-MAIL
CONTRACTOR
CITY
Sz�c
STATE
W
ZIP FAX
`1 �t C2vG�3y �tqZIR
WA STATE CONTRACTOR'S LICENSE #EXPIRATION
u'JSS2
DATE FEDERAL WAY BUSINESS LICENSE #
NAMEQ ,, i (PHONE
t, C� i C �"w RS CkLCt
MAILING ADDRESS t E-MAIL C i
APPLICANT
CITY I STATE ZIP FAX
PROJECT CONTACT
(The individual to receive and
respond to all correspondence
NAME IPHONE
t f f f {
MAILING ADDRESS I I E-MAIL (: r
concerning this application)
CITY I I
STATE
Ir
ZIP FAX
t C f r
ALTERNATE CONTACT NAME: i
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 of the reliance of the city, including its officers and employees, upon the accuracy of the
information supplied to the city as a part of this application.
SIGNATURE: DATE 09 l /10
�
R- NAME: o P J Q{
Bulletin #100 - April 14, 2010 Page I of 3 k:\Ilandouts\Perinit Application