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13-103670 iv • CITY OF A `"" V PERMIT APPLICATION Federal Way AUG % 0 2013 Cm of FEDERAL V P '/' ps pmc y PERMIT NUMBER /a � d /�. U _ lc"'3L TARGET DATE SITE ADDRESS SUITE/UNIT# 1 S®t s- (otk'' L=C-7- It I / PROJECT VALUATION ZONING ASSESSOR'S TAX/PARCEL# $ 2�liS I O✓ Z - V 0 �J / TYPE OF PERMIT ❑ BUILDING ❑ PLUMBING 0 MECHANICAL 0 DEMOLITION 0 ENGINEERING EVP/IRE PREVENTION NAME OF PROJECT MANI11--. FP—(i7-E 5A0.1 SAi 4 tn, Ci2.- PROJECT DESCRIPTION R'E 4vl°\';e PQY Ctk44,1 CAL- I P. S Yom&✓N - c A)' r4 L L Detailed description of work to P yP.cC/cl--1E t kiN I,-I(32 wp ct-ivvt lc A,L ,,LE s''kFC SSI Ot, be included on this permit only -77-11-E,v" 113 T-C} CAA C)l. €1-1 b —it:" ?I ni Irl.F A C:`r1-4i1- Mj7 i&L5cc, C t F1 CAI- 1CALS NAME PRIMARY PHONE PROPERTY OWNER i/kfcp 0 iA'i A- ,-:1•1 -k‘2.-Ni‘C S MAILING ADDRESS E-MAIL CITY STATE ZIP NAME- r 1-kDo a A� ttca— Ge-A' fC:c-s PHONE 2.c,(0'-7 z 6 ' ©q yd MAILING ADDRESS EMAIL CONTRACTOR (--lcC' (1'"'� A� lvr� s�►+heL,i1iewi-h.ec1, c„,,,,, CITY STATE ZIP FAX 'e-A'Ct-t. - \Ig- cNIc>6 ze(c•- -/ 2& C`7 WA STATE CONTRACTOR'S LICENSE# EXPIRATION DATE FEDERAL WAY BUSINESS LICENSE# Kr-4 c'O[)4 CA 1 z-/ 1 / 13 NAME PRIMARY PHONE ,�v A> ISACv.0 APPLICANT MAIM ADDRESS E-MAIL CITY STATE ZIP FAX NAME PRIMARY PHONE PROJECT CONTACT J Acy v Ck-E N.1 G Ly v--c,Ic..--r 7 to 'Cq 4 O (The individual to receive and MAILING ADDRESS EMAIL respond to all correspondence Woo 12' ' A\'e S - J'Sc4,ne )AYc', r1-1,0C)ci.to wt concerning this application) CITY STATE ZIP FAX NAME PROJECT FINANCING 0 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 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. I j SIGNATURE: DATE 0/ 1 9/2 0.t3 PRINT NAME: S 4,1 Jt k, t.--Ni Bulletin#100-January 1,2013 Page 1 of 3 k:\Handouts\Permit Application III •