12-105027CITY 4F
Federal Way
COMMUNITY DEVELOPMENT SERVICES
253-835-2607• FAX 253-835-2609
ww!.0 atoffaueratwag. conr
02�_ 16- s 0a__7
• PERMIT 4MF CO ME PL DE ENS._/
APPLICATIONCIEIVED
n 5 7012
SITE ADDRESS �
WAY
SUITE/UNIT #
CITY OF FEDERAL
PROJECT VALUATION
$
ZONING
ASSESSOR'S TAX/PARCEL #
l 6)�—
/D DO 0
-0 1? 1�1
TYPE OF PERMIT
❑ BUILDING ❑ PLUMBING ❑ MECHANICAL
❑ DEMOLITION ❑ ENGINEERING trFiRE PREVENTION
NAME OF PROJECT
(Tenant Name/Homeowner Last Name)
�i9�fi i
PROJECT DESCRIPTION
Detailed description of work to
l
be included on this permit only
PROPERTY OWNER
NAME
KC(�
PRIMARY PHONE
LING ADDMS q ,
Li �O1L l LA) ttid
E-MAIL
CITY
LSSA Qty +4 tf �� Z�£5D2 `1
NAM
e rJ
PHONE
Z5-.- Sf�
AVULING ADDRESS
..
T l(/
q
E-MAIL
CONTRACT
�A)T
9 i5 Yi l�
FAX
c
WA STATE CONTRACTOR'S LICENSE #
EXPIRATION DATE
FEDERAL WAY BUSINESS LICENSE #
NAME
,q^% dl R sin (201J7,,?41 c r_ 10A
PHONE
Z53 — 2 710 3 L
APPLICANT
MAILING ADD S
E-MAIL
CITY
STATE
ZIP
FAX
PROJECT CONTACT
NAM�� C � J , r�e�C_
Vi17�`
PHONE
Z,Sj – 2,5,5 – 7�,�j Z_
(The individual to receive and
MAILING ADDRESS
E-MAIL
respond to all correspondence
concerning this application)
CITY
STATE
ZIP
FAX
ALTERNATE CONTACT NAME: PHONE
EMAIL
PROJECT FINANCING
NAME
Er—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 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 cityy as as part of this application.
11_
<64
SIGNATURE: DATE
'W�v J t44 9/ 1et__
PRINT NAME: `
Bulletin #100 –January 1, 2011 Pagel of 3 k:�Handouts\Permit Application