14-103254 •
art OF PERMIT PPLI&SON
Federal Way
JUL 0 3 2014
PERMIT NUMBER 14 _ I 0 : Z _ f p CITY OF FEDERAL WAY
TARGET DATE CDS
SITE ADDRESS SUITE/UNIT M
//a9 5 3 ff& s4,
PROJECT VALUATION ZONING ASSESSOR'S TAX/PARCEL*
$ al � o I C 9 - 9 0 �1 a
TYPE OF PERMIT CI BUILDING ❑CPLUMBING 0 MECHANICAL 0 DEMOLITION 0 ENGINEERING y9
/FIRE
yPREVENTIO(N r
NAME OF PROJECT 1/0 / 6 3 /0` ' s4.. C A SCC' � , l lam' '/Ot /A l.._
PROJECT DESCRIPTION 41019 41—
�Oie. victual jic5
Detailed description of work to ADt) 9- gin/Ace. Deaee-tetec
be included on this permit only
Au
-1(5
ei,t5- - 4 y 4 e
NAME PRIMARY PHONE
PROPERTY OWNER GIC.C1410P MAAAA.Q
MAILING ADDRESS E-MAIL
//O9
CITY STATE ZIP
F �..�wY w� ,
NT:,
PHONE
es S s 4')- -m o0o
MAILING ADDRESS
�V690 95A1- E Si- UAA-k- Dior C&A ,c%,I Jc&,sw,uc-
CONTRACTOR YSTATE ZIP
�/[�
CI,�'Y 1 WFI q4j5)._ FAX
WA c leScLICENSEONT R'S LICENSE II EXPIRATION DATE FEDERAL WAY BUSINESS
es ?O 491 1/ /607 /iv,v 11-49-1641,6,56-PL
NAME PRIMARY PHONE
5 Ati"e 4S tf4Qpue_ Yds-mit I-010o
APPLICANT MAILING ADDRESS
Cruoki:Se.C411totetIA FP.05
CITY STATE ZIP FAX
NAME A f �l ,A-n.- 9 PRIMARY PHONE
PROJECT CONTACT /`�',YA ,WA! el vY
(The individual to receive and MAIIdNG ADDRESS E-MAIL
respond to all correspondence /7 (94 J .
concerning this application) C STATE ZIP FAX
NAME
FINANCING
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 suppliededto the city as a part of this application.
L /„...... .............--------
SIGNATURE: DATE .7-..X--111
PRINT NAME: eltie Se. Clei+1,04
45
Bulletin#100—January I,2013 Page 1 of 3 k:\Handouts\Permit Application