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16-100937
CITY OF '� ' -y Federal Way PEith!" NUMBER �ECEIV � ED PERMIT APPLICATION P=mT CENTER + 33325 8th Avenue South + Federal Way, WA 98003-6325 FEB 2 2 2016 253-835-2607 + FAX 253-835-2609 + permitcenter(Lcitvoffederalway.com CITY OF FEDERAL WAY F TARGET DATE SITE ADDRESS SUITE/UNIT 0 pla"e- PItCkTF= VALUATION ZONING ASSESSOR'S TAX/ CEL # TYPE OF PERMIT ❑ BUILDING ❑ PLUMBING ❑ MECHANICAL ❑ DEMOLITION ❑ ENGINEERIN FIRE PREVENTION NAME OF PROJECT j PROJECT DESCRIPTION / �r / p 1 l 6-'1 5 t tTom'^ t"t� Detailed description of work to be included on this permit only NAME PRIMARY PHONE PROPERTY OWNER MAILING ADDRESS EMAIL CITY ZIP (STATE N COgNe—CL�AC)1� PHONE G-V�' 3360 MAILING ADDRESS / `I.�9 S' /3 5+- PkL� VEMAIL Eric CONTRACTOR CITY� LAX � � ZIPr12vt 1<3169 WA STATE CONTRACTOR'S LICENSE # EXPIRATION DATE FEDEVAL WAY BUSINESS LICENSE # ? qKf- ms -©r-±o s -0e, NAM c'Q3-�/cam 25� smoms "DREW ' EMAA. APPLICANT /UMG STATEZIP �p C�G�3 FAS N"� e PRIMARYPHONS Zv10' L��S3 PROJECT CONTACT V l v MAILING ADDRESS lEMAKL &$ 91 -1h CDSCtl .(II' .0 (The individual to receive and respond to all correspondence CITY STATE ZIP L..,) c, 8? FAX 4 �/3S-33S-G conceming this application) PROJECT FINANCING NAME ❑ OWNER -FINANCED When value is $5,000 or more MAILING ADDRESS, CITY, STATE, ZIP PHONE (RCW 19.27.095) I cert fy under penalty of perjury that I am the property owner or authorized agent of the property owner. I certVy 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 fiurther agree to hold harmless the City q%Federoal Way as to any claim (including costs, expenses, and attorneys' fees incurred in the investigation and dgfense of such clams), which may be made by any person, including the undersigned, and flied against the city, but only where such Yah! arises out of the reliance of the city, including its officers and employees, upon the accuracy of the information supplied tha city as a part of this application. K4A SIGNATURE: DATE PRINT NAME: Bulletin # 100 — January 29, 2016 Page 1 of 2 k:\Handouts\Perinit Application :tarot "M