13-103771CIN OF A
Federal Way
REC*VED
AUG 2 7 2013
0
PERMIT APPLICATION
/� CITY OF FEDERAL WAY
PERMIT NUMBER L 5
_ /,cr 7 —2 ` _ E
TARGET DATE
SITE ADDRESS
—
SUITE/UNIT #
I 5��
i
.
PROJECT VALUATION
ZONING
ASSESSOR'S TAR/PARCEL #
TYPE OF PERMIT
a
❑ BUILDING ❑ PLUMBING ❑ MECHANICAL ❑ DEMOLITION ❑ ENGINEERING RE PREVENTION
NAME OF PROJECTjejl
j
PROJECT DESCRIPTION
Detailed description of work to
be included on this permit only
PROPERTY OWNER
NAME �, PRIMARY PHONE
NG ADD � � • �•.� �/ E-MAIL
CI - STATE ZIP
C 6 !
�^
MAILING AD REBS%[/ E -
L / f� G
CONTRACTOR
CI'
S`J71
(/,�
FAX ..
WA STATE CONTRACTOR'S LIC SEM ERPIRATIO✓N DAT FEDERAL WAY BUSINESS CENSE #
i/ /
NAME c� PRIMARY PHONE
MAILING ADDRESS E-MAIL
APPLICANT
CITY
ST
ZIP FAX
NAME PRIMARY PHONE
PROJECT CONTACT
&�L4_t)e
MAILING ADDRESS E-MAIL
(The individual to receive and
respond to all correspondence
CITY
STATE
I ZIP FAX
concerning this application)
PROJECT FINANCING
NAME OWNER -FINANCED
Required value of $5,000 or more
MAILING ADDRESS, CITY, STATE, ZIP PHONE
(RCW 19.29.095)
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 clairN, which may be made by any person, including the undersigned, and filed against the city,
but only where such claim arises out of the of the city, including its officers and employees, upon the accuracy of the
information supplied t s a lication.
SIGNATUR DATE
r
PRINT NAME
Bulletin #100 —January 1, 2013 Page I of 3 k:\Handouts\Permit Application