13-101698 0
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CITY OF . -- E] PERMIT APPLW6E1\166N
Federal Way •
APR 18 2013
PERMIT NUMBER ( , _ ( 0 \ ( 01, e) o CITY OF FEDERAL WAY
TARGET DATE CDS
SITE ADDRESS SUITE/UNIT#
IL! ELS '21.'"n .7-- .1e.(f) R?
PROJECT VA TION ZONING ASSESSOR'S TAX/PARCEL#
$ MoD 16 v o 5 o - o t o
TYPE OF PERMIT ❑ BUILDING ❑ PLUMBING ❑ MECHANICAL ❑ DEMOLITION ❑ ENGINEERING FIRE PREVENTION
NAME OF PROJECT CettOcC (0^ I L2.1.
PROJECT DESCRIPTION AE cc,A1 6 cAs 4-`v4'-ker
Detailed description of work to
be included on this permit only
NAME PRIMARY PHONE
PROPERTY OWNER \'\ ` PCl-tGC CO?eAk? 5
MAILING ADDRESS E-MAIL
kIlkatVA `'.0.130( ar7a�J,�/7 �A'/
CITY -0(10.t.1-6 STATE
ZI I 1 'C V t��y /�
PHONE
NAME + iel �l p�`T'J l` P' `G` �3 r VS/ V!3(/
MAILING1ADDRESS `ten1 t
CONTRACTOR � /�irpc�r-4- y ic,,1 5 ` fir.r rn (`I TC.'�l i5'lI,516n,1CN)'on
CITY � \ A ZIP n� ` FAkb- W -70114
W
vu,, aC3 4,11 PibS DATE/ /✓ 20-00 AgII��II1`'IVES�LIC�S
NAME MCHC I V c t IWIA'(N (Vias ,`I /40, ck A I0-m PRIM°Y_�HONE d-3 18
APPLICANT MAILINGD Y DURESS 1 E-MAIL rV�`_f "•nLL/JJ�
30 QtP 11 Vet, / Q '1Y1��1,1�iiidal(n��jlit5iii it,5 �IG1tci din
CITY ,0_01.4 Il /IT/AZ
/'7 2IP CI V'3L r
FAX r7V 1 9
NAME PRIMARY PHONE
•
PROJECT CONTACT Dll� /�` E-MAIL�,S CR?I I rU/•. --
(The individual to receive and MAILING ADDRESS l
respond to all correspondence
concerning this application) CITY STATE ZIP FAX
NAME
PROJECT FINANCING ❑ 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 claim(including costs,expenses,and attorneys'fees incurred in
the investigation and defense of such claim), which may be made by arty 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. y
SIGNATURE: ��/'"`� ��� DATE / /7-c 73
PRINT NAME: NU'rVL Ail I Gt N.
Bulletin#100—January 1,2013 Page 1 of 3 k:\Handouts\Permit Application