18-101653 RECEIVED
CITY OF ,4,..,,,,,...., APR 8 2018 PERMIT APPLICATION
Federal WayPEzT CENTER+33325 8th Avenue South+Federal Way,WA 98003-6325
CITY OF FEDERAL WAY 253-835-2607+ FAX 253-835-2609+permitcenter(.citvoffederalway.com
COMMUNITY DEVELOPMENT
PERMIT NUMBER I 8 �L.l_ 1 0 I V 3 _ F ? 0/Pc
IIIITARGET DATE
SITE ADDRESS
SUITE/UNIT S
3/ 71 ! AIC/ ifLit -i-
PROJECT VALUATION ZONING ( ASSESSOR'S TAX/PARC-ELI
$ s-lvv c,D 2 ( v y _ I 2- 2- s
TYPE OF PERMIT
0 BUILDING 0 PLUMBING 0 MECHANICAL 0 DEMOLITION 0 ENGINEERING/FIRE PREVENTION
NAME OF PROTECToi,.../111/Alli7 jj) A )
,e iiii 4C i cSi.1 SOA%FA 3 3T .sz i G.)/74 A4/}5'UL /Z/02 Iii U
PROJECT DESCRIPTION /
Detailed description of work to 4/x./10,2 hicvs.0 g t' :te t' 'J'/U..V -o'ys'Te4t
be included on this permit only
NAME
PRIMARY PHONE
PROPERTY OWNER MAILING ADDRESS E-MA L
CITY STATE ZIP
NAMEPHONE
,4!,e (,,() ,, f A/lo7tCf,4 ..v Z.5.3-31 -0737
MAILING ADDRESS E-MAIL
CONTRACTOR L
CITY STATE ZIP
fryil)/✓P 10A X 37, `cr,cmeA5 ...0 t r
WA STATE COxTRAC e IGEN i EXPIRATION BUSINESS
jW 3 3S -to�
i�i�i2�- ° ��� �
2 ,�1 ,j g o
NAME PRIMARY PHONE
APPLICANT MAILING ADDRESS E-MAIL
CITY STATE ZIP FAX
NAME PRIMARY PH `
PROJECT CONTACT re.ut , -(7i2o7o' r�2 X53-7
. ,G9 514
(The individual to receive and MAILING ADDRESS
respond to all correspondence 3 7 26 Li) 5'r /e f , 71-s rL/un`f s6 r 714 A y7e,,O rr
concerning this application) CITY STATE ZIP FAX
/jlei sr, 4A yay"%
NAME
PROJECT FINANCING
0 OWNER-FINANCED
When value is$5,000 or more ING ADDRESS,CITY,STATE,ZIP PHONE
(RCW 1927.095)
I certify under penalty of perjury that I am the property owner or authorised 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 authorised 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 ap., ' ation.
SIGNATURE: J �/ /_ DATE 49.--. �' - / ;
PRINT NAME: _ -----G L' j"i20j9'£/2..
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Bulletin 4100-January 29,2016 Page 1 of 2 k:\Handouts\Permit Application