13-100361QTY OF 4 A
Federal Way
REISIVED
JAN 2 3 2013
PERMIT APPLICATION
CITY OF FEDERAL WAY
S.
PERMIT NUMBER ' ✓ — ' �D I _ O (D
— TARGET DATE
SITE ADDRESS\\
SUITE/UNIT #
S.
PROJECT VALUATION
ZONING
ASSESSOR'S TAX/PARCEL /
$ -565 0 , 0 e)
— — — — — — - — — — —
TYPE OF PERMIT
0 BUILDING 0 PLUMBING 0 MECHANICAL 0 DEMOLITION 0 ENGINEERING V FIRE PREVENTION
NAME OF PROJECT
FO>WAL WAY Ll NG C ! /�S
A "s R 'a o o 5 �r
PROJECT DESCRIPTION
Detailed description of work to
be included on this permit only
PROPERTY OWNER
NAME
PRIMARY PHONE
3" 32'5
MAILING ADDRESS
rtes, S 3-2r4 _}L, g c C (--1
E-MAIL
CITY
e.-,L,a 'w
STATE
I V- V%
ZIP
CNS 603
NAME [An"'4,41'N \ NiY<- w\
PHONE
MAILING ADDRESS
E-MAIL
(L �" ' S
CONTRACTOR
CITY
��WCC-rnY�J�
STATE
jl%l/�
ZIP
�t J''�T
FAX
FA
WA STATE CONTRACTOR'S LICENSE N
EXPIRATION DATE
FEDERAL WAY BUSINESS LICENSE N
PRIMARY PHONE
—t
APPLICANT
MAILING ADDRESS
E-MAIL
CITY
STATE
Ll%w 1
ZIP
C'i, y6
FAX
NAM
PRIMARY PHONE
PROJECT CONTACT
(Tine individual to receive and
MAILING ADDRESS
E-MAIL
respond to all correspondence
CITY
STATE
ZIP
FAX
concerning this application)
PROJECT FINANCING
NAME
OWNER -FINANCED
Required value of $5,000 or more
MAILING ADDRESS, CITY, STATE, ZIP
PHONE
(RCW ]9.27.095)
1 certify under penalty of perjury that I am the property owner or authorized agent of the property oumer. I certify that to the best
of my knowledge, the information submitted in support of this permit application is true and correct. 1 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 Taws.
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 city as a part of this application.
C
l
SIGNATURE: DATE
PRINT NAME:�L' S (-I C, L ✓-
Bulletin # 100 - January 1, 2013 Page 1 of 3 k:\Handouts\Permit Application