12-103249 % RECEIV Ed. -
CITY 2012 PERMIT SF MF CO ME PL DE EN
3
PLICATION
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f PROJECT
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PROJEC'P
1-looleounier Name) 'Ii
D BUILDING U PLUMBING D MECHANICAL
TYPE OF PERMIT
DEMOLITION U ELECTRICAL Id ENGINEERINGX,FIRE PREVENTION
P.O.TEr:T DESCRIPTION pep 1,4- 1.- pp Li is-J- / Pr ik ic-te
2,(o7cd %,•rii)tion oI 11)01*
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177::Srk PEOPLE";
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PRIMARY PHONE
MAILING ADDRESS,CITY,STATE,ZIP E-MAIL
C\V."ii.:R IS AI,EIO: p CONTRACTOR ID APPLICANT 0 PROJECT CONTACT
NAME PRIMARY PHONE
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MAILING ADDRESS,CITY,STATE,ZIP FAX
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WA STATE CONTRACTOR'S LICENSE EXPIRATION DATE FEDERAL WAY BUSINESS LICENSE#
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NAME PRIMARY PHONE
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PLICAd
MAILING ADDRESS,CITY,STIFF:,ZIP FAX
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CONTAcr NAME PRIMARY PHONE
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/(Jsi, l t /1 C0lTS/'O 'dell 0 MAILING ADDRESS,CITY,STATE,ZIP FAX
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ALTERNATE CONTACT NAME: PRIMARY PHONE E-MAIL
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NAME
0 OWNER-FINANCED
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f 0(6 U MAILING ADDRESS,CITY,STATE,ZIP PRIMARY PHONE
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4 1 elk um In iwnalty or,wrjury that I am the property owner or authorized agent of the property owner.I certify that to the best
ttt '(' tI ;,,format i I,,submitted in support of this permit application is true and correct. I certify that I will comply with
Ciilj Feder-(11 Woy regulations pertaining to the work authorized by the issuance of a permit. I understand that the
is,sou - of this a-tdocs not remove the owner's responsibility for compliance with local, state, or federal taros regulating
,-onst oction Cr envir,rir.zentrzl laws.
r-t,ler-agree lo 001(1 h-rirmless the City of Federal Way as to any claim(including costs, expenses, and attorneys'foes incurred
in the hwes,igation anti defense of such claim), which may be made by any person, including the undersigned, and filed against the
city, bat only where such claim arises out of the reliance of the city, including its officers and employees, upon the accuracy of the
irtfortootiot;saly)liwt to the city as a part of this application,
DATE
/I-5/1-Z--
I'RINAME:
201(1 Page I of d k:\ lanclouts\Pennit Application