10-102100Ak
Federal Way
COMNttr -ITY DEVELOPMENT SERVICES
2.5.;-8 35-2607• FAX 25.;-835-2609
*PERMIT
APPLICATION
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IVC:[)E PL DE EN FP
MAY 2 0.2010
CITY OF FEDERAL WAY
SITE ADDRESS � � co � � � ��, �� ���� `; � � LJZ)� �
SUITE/UNIT N
PROJECT VALUATION
ZONING
ASSESSOR'S TAX/PARCEL M
$ L 1 c c -,c
9 OL- �-- - c '3 - -L C, S
TYPE OF PERMIT
❑ BUILDING ❑ PLUMBING ❑ MECHANICAL
❑ DEMOLITION ❑ ENGINEERING FIRE PREVENTION
NAME OF PROJECT
(Tenant Name/Homeowner Last Name)�
PROJECT DESCRIPTION
Detailed description of work to
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be included on this permit only
PROPERTY OWNER
NAME PRIMARY PHONE
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MAILING ADDRESS .i }��
E-MAIL �o
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CITY STATE �V'a "V'✓T ZIPOJ'ji7C"
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PHONE
MAILING
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E-MAIL
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CONTRACTOR
CITY
STATE
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ZIP
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FAX
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WA STATE CONTRACTOR'S LICENSE i EXPIRATION DATE
112
FEDERAL WAY BUSINESS LICENSE li
NAME
V
PHONE
APPLICANT
MAILING ADDRESS ii
E-MAIL
CITY STATE Z1PFAX
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PROJECT CONTACT
NAME
PHONE
(The individual to receive and
MAILING ADDRESS
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E-MAIL
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respond to all correspondence
concerning this application)
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STATE
WA
ZIP
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FAX
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ALTERNATE CONTACT NAME: PHONE
E-MAIL
PROJECT FINANCING
NAME
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E] OWNER -FINANCED
Required value of $5, 000 or more
MAILING ADDRESS, CITY, STATE, ZIP
PHONE
(RCW ]9.27.095)
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 as apart of this application.
city
SIGNATURE: / Vim+ DATE S� .� C IC
1 � —"� �(Ak \ k.,L—
PRINT NAME:
Bulletin #100 — April 14, 2010 Page 1 of 3 k:\Handouts\Permit Application
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