11-100864a"OF V&
Federal Way
COMMUNITY DEVELOPMENT SERVICES
253-835-2607• PAX 253-835-2609
www. dtvol%deralwau. com
•PERMIT
APPLICATION
U _100904
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MAR 0 4 'w`1
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SITE ADD � 0 � I 4 'ST—T t.� l� �
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I I D S
PROJECT VALUATIQ�
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ZONING
ASSESSOR'S TAX/PARCEL # ^
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TYPE OF PERMIT
❑ BUILDING ❑ PLUMBING ❑ MECHANICAL
❑ DEMOLITION ❑ ENGINEERING FIRE PREVENTION
NAME OF PROJECT
(Tenant Name/Homeowner Last Name)
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'RrPROJECT �''
DESCRIPTION
Detailed description of work to
S �-
be included on this permit only
PROPERTY OWNER
NAME
PRIMARY PHONE
MAILIN ADDRESS
E-MAIL
5 -
CITY
ZIP
t3a
NAME
PHONE
5-71 —Z
MAILING ADDRESS
L q
G(1•
CONTRACTOR
(
CITY
STA E
ZIP
FAX
WA STATE CONTRACTOR'S LICENSES
T_V
EXPIRATION DATE
FEDERAL WAY BUSINESS LICENSE #
N
/31 /ZD1
xAME ®
PHONE
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M&1bffWADDREs8
E-MAIL
APPLICANT
C ^
STATE
ZIP
FAX
PROJECT CONTACT
NAME
PHONE \�
(The individual to receive and
lT)-
MAILING S
'
E-MAIL
respond to all correspondence
concerning this application)
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CM
STATE
UN ekV
ZIP �ry
FAX
ALTERNATE CONTACT NAME:
PHONE
E-MAIL
PROJECT FINANCING
NAME
OWNER -FINANCED
Required value of $5,000 or more
MAILING ADDRESS, CITY, STATE, ZIP
PHONE
(RCW 19.27.095)
I certify under penalty of perjury that I atm the property owner or authorized agent of the property owner. I certify that to the best
of my knowledge, the Wormation 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 su claim arises out of the reliance of the city, including its officers and employees, upon the accuracy of the
ir}formation suppli city as of this application.
7
SIGNATURE: DATE
PRINT NAME ......__ •� L ��
Bulletin #100 -April ig,`�ir Page 1 of 3 k:\Handouts\Permit Application
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