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Federal Way
AUG 0 g 2014 PERMIT APPLICATION
CITY OF FEDERAL WAY
CDS
PERMIT NUMBER D S 1 — — TARGET DATE
Bulletin #100 — January 1, 2013 Page 1 of 3 k:\Iiandouts\Permit Application
SUITE/UNIT Y
SITE ADDRESS �"
328th St, Federal Way WA
PROJECT VALUATION
ZONING
SOR'S TAR/PARCEL 4
$ 50,000.00
�14-1-3 _1 8_-0 -Q- 2Q — - — — — —
TYPE OF PERMIT
❑ BUILDING ❑ PLUMBING ❑ MECHANICAL ❑ DEMOLITION ❑ ENGINEERING )p FIRE PREVENTION
NAME OF PROJECT
Celebration Senior Living �Ll-I LC-• 6 [
Monitired Fire 61am System U
PROJECT DESCRIPTION
Detailed description of work to
be included on this permit only
NAME
PRWARY PHONE
PROPERTY OWNER
Celebration Senior Living
MAILING ADDRESS
201 27th Ave SE PAii 1 d Sili t- 'inn
FIN AH.
CITY
W
wrE U174
NAME
PHONE
Evergr
-56
NAILING ADDRESS
PO Box 849
E-MAIL
@net-Nx31=. QIt
l�
'1
'12�
CONTRACTOR
CITY
STATE
ZIP
FAX
Sumner
WA
98390
253-770-1767
WA STATE CONTRACTOR'S LICENSE !
EXPIRATION DATE
FEDERAL WAY BUSINESS LICENSE f
NAME
PRIMARY PHONE
Somas Electrical
MAULING ADDRESS
E-111AIL
APPLICANT
CITY
STATE J
ZIP
FAX
NAME
PRIMARY PHONE
PROJECT CONTACT
Hcb GAIaL
2-93-606-7085
MAILING ADDRESS
M -MAIL
(The individual to receive and
respond to all correspondence
Saae
CITY
STATEZIP
FAX
Concerning this application)
NAME
OWNER -FINANCED
PROJECT FINANCING
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 irtformation submitted in support of this permit application is true and correct. I certVy 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 su lied to t city as apart oft is ap cation.
SIGNATURE: DATE ^ ` \!7)
PRINT NAME:
Bulletin #100 — January 1, 2013 Page 1 of 3 k:\Iiandouts\Permit Application