13-101701• 0
�?Pn;,� PERMIT APPLICATION
Federal Way RECEIVED
RECEj
VED
PERMIT NUMBER l / / _ 1 0 _00 APR 18 2013
✓✓✓ 111TARGET DATE CM OF FEDERAt WAY
SITE ADDRESS
m 'S 57
SUITE/
PROJECT VALUATION
ZONING
ASSESSOR'S TAX/PARCEL #
TYPE OF PERMIT
❑ BUILDING ❑ PLUMBING ❑ MECHANICAL ❑ DEMOLITION ❑ ENGINEERING-5k.PIRE PREVENTION
NAME OF PROJECT
' aTc_ `
` _ d
PROJECT DESCRIPTION
Detailed description of work to
be included on this permit only
NAME (
PRIMARY PHONE
PROPERTY OWNER
e 5
MAII.D�iG�ADD S
" J
E-MAIL
CITY (1
�
STATE
ZIP
NAME
�
PHONE
• i
MAILINGAD ESS
AKIDO(+c'�
SMAI
CONTRACTOR
CITY nSTATE
ZIP ��
FA7; ^ • q -^ ,
WA S ATE CONTRACTOR'S LICENSE # PIRATION DATE
.11
FEDERAL WAY BUSINESS LICENSE #
W�N;81625 UL
NAME
PRIMARY PHONE
MAILING ADDRESS
E-MAIL
APPLICANT
CITY
STATE I
ZIP
FAX
NAME�// Nn^ ^ t
PRIMARY PHONE
PROJECT CONTACT
QCtt IVC^_ K' n
MAII DIG ADDR
VA
(The individual to receive and
respond to all correspondence
f t
M1"V'*1�'&&"1\L61
CITY /� STATE zip
1` Vi
FAX ^^t
concerning this application)
PROJECT FINANCING
FAME
❑ 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 clainl (including costs, expenses, and attorneys' fees incurred in
the investigation and defense of such claim/, which may be made by any per on, including the undersigned, and filed against the city,
but only where such claim arises out of the reliance of the city, includirt its officers and employees, upon the accuracy of the
information supplied to the cit as a part of this application.
IYI/
SIGNATURE: DATE A
PRINT NAME:
Bulletin #100 -January 1, 2013 Page I of 3
k:\Handouts\Permit Application
.tom
, VA.