13-101702CITY OF `
Federal Way
APD PIPO,77
0
PERMIT AMrAUSTION
APR 18 2013 V 00
PERMIT NUMBER �J _ l O ' O 2 _ 100 CITY OF FEDERAL WAY
L TARGET DATE CDS
SITE ADDRESS
SUITE/UNIT #
yL'y�
PROJECT VALUATION
9a)
ZONING
ASSESSOR'S TAX/PARCEL # 1
1 0
Q —i— � —1— D -�-- —CL
TYPE OF PERMIT
❑ BUILDING ❑ PLUMBING ❑ MECHANICAL ❑ D MOLITION ❑ ENGINEERINGVISI,FIREPREVENTION
NAME OF PROJECT
a� V Q —
PROJECT DESCRIPTION
Detailed description of work to
be included on this permit only
NAME
PRIMARY PHONE
PROPERTY OWNER
MAILING ADDRESS ^` ^
*^VIZI
EMAIL
CITY
76 41
\l
STATE
NAME
1V kAW am v
SIV CJ D
MAILING ADD S
VfAWS
EMAIL
1� 1N,V�
mmG�
CONTRACTOR
CITY r � �t
V
TAE
ZIP/1' / 1 e5 / J
V (TJ J(/�\
FAX I f
L,
W STATE CONTRACTi ' EASE # �EX I Ol� DATE
(P�- (jl
FEDERAL WAY BUSINESS LICENSE
'
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NAME
PRIMARY PHONE
MAILING ADDRESS
EMAIL
APPLICANT
CITY
STATE
ZIP
FAX
NAME r
-I I
PRIMARY PHONE q(
PROJECT CONTACT
1 v IG�6 l t/ �f
(J
MAILING ADD
EMA[
-
(The individual to receive and
respond to all correspondence
lr
CI S
mmnq
FAX
concerning this application)
PROJECT FINANCING
NAME
0 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 Wa as to any claim (including costs, expenses, and attorneys' fees incurred in
the investigation and defense of such claim), which may be ade by any person, including the undersigned, and filed against the city,
but only where such claim arises out of the reliance of he city, including its officers and employees, upon the accuracy of the
information supplied to the city as apart of this applicati
SIGNATURE:
PRINT NAME:
/ 14 ./
J
Bulletin #100 -January 1, 2013 Page l of 3 k:\Handouts\Permit Application
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