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15-104796ciry of Federal Way PERMIT NUMBER -15 &EMM PERMIT hPLICATION SEP 21 2015 CITY OF FEDERAL WAY V " 91� fc F ? TARGET DATE SITE ADDRESS SUITE/UNIT # L�ECT � UATION �© ZONING ASSESSOR'S TAX/PARCEL # � � � 1 _ TYPE OF PERMIT ❑ BUILDING ❑ PLUMBING ❑ MECHANICAL ❑ DEMOLITION ❑ ENGINEERING WIRE PREVENTION NAME OF PROJECT C WN L4 "5 . A6vt - A < 44 PROJECT DESCRIPTION Detailed description of work to \ OWit', V%1 Gee c� S be included on this permit only NAME PRIMARY PHONE PROPERTY OWNER MAILING ADDRESS E-MAIL CITY STATE ZIP NAME t - & Irl ONE PH -26, 6 W l� CAX� t/L 7�'C \ l MAILING ADDRESS 6aowV Ste- E-MAIL ' f'C CONTRACTOR IQA �`(� CITY STATE ZIP FAX WA STATE CONTRACTOR'S LICENSE # EXPIRATION DATE FEDERAL WAY BUSINESS LICENSE # fL X88 Yi 6 i NAME PRIMARYPHONE 6 6/ S f 14 coo c� Z© 7cZ MAILING ADDRESS �. E-MAIL ' APPLICANT ✓.N ll 000 C CITYV , ' A a(jl �•eV� STATE ZIP �/ j 6 4 1/7 FAX NAME PRIMARY PHONE PROJECT CONTACT MAILING ADDRESS E-MAIL (The individual to receive and 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 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 taws 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 fled against the city, but only wheresuch laim arises out of the reliance of the city, including its officers and employees, upon the accuracy of the information supplied he city as apart of this application. SIGNATURE: DATE 1 PRINT NAME: E,) -t 0 Bulletin # 100 - January 1, 2013 Page i of 3 k:\Handouts\Pelmit Application M