11-100664CITY of /&
Federal Way
COMMUNITY DEVELOPMENT SERVICES
253-8352607• FAX 253-835-2609
www. ci�i%deml wau. caa
4iPERMIT
APPLICATION
it - 1 00 & 64 -
MF CO ME PL DE EN FP
:SUBMI1 D -
FEB 16 2011
SITE ADDRESS
CI
gFRO£RRAL WAY
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� i 4 S'i
CDS
PROJECT VALUATION
ZONING
ASSESSOR'S TAX/PARCEL #
TYPE OF PERMIT
❑ BUILDING ❑ PLUMBING ❑ MECHANICAL
❑ DEMOLITION ❑ ENGINEERING FIRE PREVENTION
NAME OF PROJECT
(Tenant Name/HomeoumerLast Name)
� _ w 1 u /) C r-
1 i r y C ir-1
PROJECT DESCRIPTION
'
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Detailed description of work to
be included on this permit only
PROPERTY OWNER
NAME ' 1 , T ,
PRIMARY PHONE
MAILING ADDRESS
B -MAIL
CITY
. STATE
ZIP
NAME
PHONE
Z
MAILING ADDRESS
// 0 .2 /re 1, e7x'e ° "J
E -MAH
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CONTRACTOR
CITY
;; � r, Z.
STATE
I 'Aid
ZIP
2,
FAX
2IS314's I-- 2 312 -
WA STATE CONTRACTOR'S LICENSE #
[717c—.CAF[ e^id-
EXPIRATION DATE
114141 ///
FEDERAL WAY BUSINESS LICENSE #
-c7D
NAME
PHONE
APPLICANT
MAILING ADDRESS
E MAD.
CITY
STATE
ZIP
FAX
PROJECT CONTACTPHONE
(The individual to receive and
NAME/
C "7W1S .eeo /
2S 'Eod 42 t %
MAILING ADDS
110.21 AI /��
E-MAIL
/[� � /,,� /yl�i2Qt/J
respond to all correspondence
concerning this application)
CITY j ,
S'K'ATE
ZIP
FAX
ALTERNATE CONTACT NAME:
PHONE
E-MAIL
/V/,w
PROJECT FINANCING
Required value of $5,000 or more
NAME
OWNER -FINANCED
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 ir4j'ormation 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 flied 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
injbrmation supplied to the city as a part of this ap
SIGNATURE:
DATE
l6
PRINT NAME: -
i l5' !y
Bulletin #100— April 14, 2010 Page 1 of 3 k:\Handouts\Permit Application
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