12-102197r
COMMUN17Y DEVELOPMENT SERVICES
253-835-2607• FAX 253-835-2609
41 www.dtuoffederalwau.com
My OF 'A
Federal Way
*PERMIT
APPLICATION
-1C21(:37
706 MF CO ME PL DE EN FP
RECEIVED
1:1— ! 1 I -SS V0> * AAAV 17 %ni%
SITEADDRESS
SUITE/UNIT #
z/ 5 3�iDµ Sir FE '7v-vztr=- tIlI1A- # 915003 crryOF
FEDERAL WAY
PROJECT VALUATION
ZONING
ASSESSOR'S TAX/PARCEL #
$ Zqq(
A -3
-T -q- z r�- 2-- 0- - 0
TYPE OF PERMIT
❑ BUILDING ❑ PLUMBING ❑ MECHANICAL
❑ DEMOLITION ❑ ENGINEERING PREVENTION
NAME OF PROJECT
(Tenant Name/Homeoumer Last Name)
�
ALV S �/�` `A
PROJECT DESCRIPTION
Detailed description of work to
1 t
be included on this permit only
�AXOAt -0 S
PROPERTY OWNER
NAME� PRIMARY PRONE
C WAA ` TVbv 1✓R Z51T- 9(1(- 07E Z
BARING ADDRESS
M ST
E -MAB.
CITY - STATE I ZIP
NAME
t - of cC i61c •
PHONE
106 -G -m- 03
MAIIdNG ADDRESS
�% N t �In'3i.1 BLV'a.
E -MAB.
Fit»JE
CONTRACTOR
C_
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WA
�leaoo
FAX S-gg76
WA STATE CONTRACTOR'S LICENSE # EXPIRATION DATE
WAY BUSINESS LICENSE #
NAME EVA- l ,eatsgc�
PHONE -730- 164��.
MAUING ADDRESS
0 1.1 $ wa
E-n/tw.
CJMJ FOC—we , o
APPLICANT
CITY ffi&4x,-IA
STATE
'LC
ZIP M Q `
V
FAX753-135'-
13 � q q 1
PROJECT CONTACT
xAn�
VA+J "IS, %A0
iia
-17-90 -Mr-
(The individual to receive and
MAKING ADDRESS _ . — I
101 W O ( SUM
E-MAIL
t to - d +
respond to all correspondence
respond
concerning this application)
STATE
ZD' �
FAX TO -79!C-
$!C+ACITY
LTERNATE CONTACT NAME: PHONE
ALTERNATE
r 'all
E -MAB.
�.✓ tj Fage-00
PROJECT FINANCING
NAME
OWNER -FINANCED
Required value of $5.000 or more
(RCW 19.27.095)
MAII.IIVG ADDRESS, CITY, STATE, ZIP
PHONE
I certify under penalty of perjury that I am the property owner or authorized agent of the property Domer. I certVy that to the best
of my knowledge, the information submitted in support of this permit application is true and correct. I cert{fy 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 Way as to any claim (including costs, expenses, and attorneys' fees incurred in
the investigation and defense of such claim) In y be made by any person, including the undersigned, and filed against the city,
but only where such claim arises out of rel' n of the city, including its officers and employees, upon the accuracy of the
information supplied to the city as a this p ation.
SIGNATURE: DATE
PRINT NAME:
Bulletin #100 - January 1, 2011 Page 1 of 3 k:\Handouts\Pennit Application
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