15-106132 •
Federal Way PERMIT APPLW�IEIVEDN
{ �/ry�, DEC 04 2015
PERMIT NUMBER _ I ( _3 7 f 1
_ TARGET DATE CITY OF FEnFRQL WAY
CDS
SITE ADDRESS SUITE/UNIT#
3t15(46 3yyT"— sc�`f 5c) I-r-C- I3S- (=-6-1)611-Pt LAN / 3s�
PROJECT VALUATION ZONING / ASSESSOR'S TAX/PARCEL S
i] � c - 2S.-
c4cbTYPE OF PERMIT ❑ BUILDING ❑ PLUMBING ❑ MECHANICAL ❑ DEMOLITION ❑ ENGINEERING J'FIRE PREVENTION
NAME OF PROJECT -6-5 d LZcp
PROJECT DESCRIPTION R-CrLoLp,T-t AJ Ce F (LC C-4-//C
r- e
Detailed description of work to
be included on this permit only
NAME PRIMARY PHONE
PROPERTY OWNER iL`f \&.) -} -r
MAILING ADDRESS E-MAIL
Com, o X `6`1 -1
CITY STATE ZIP
C-41k 2LS3 s c> C. \ ci/cp t `6
NAME PHONE
(tc 5 YSTE-ev% L (-51- i-J(. a53-9S1-(006(65-
MAILING ADDRESS E-MAIL
CONTRACTOR 1 C-0 IINGC 12.(J Sv r -L 1"MC IM@ .Cr4I SYSTritAStJesc.eom
CITY ST4TE ZIP FAX
wSZ\ 5`0)4
WA STATE CONTRACTOR'S LICENSE S EXPIRATION DATE FEDERAL WAY BUSINESS LICENSE M
`tc1-E5WL cpSSLc..) (0 //(-v / 11 t9-`b7-aSfL+o545141-4696-BL
NAME PRIMARY PHONE
APPLICANT MAILING ADDRESS E-MAIL
CITY STATE ZIP FAX
NAME PRIMARY PHONE
PROJECT CONTACT tANTC L' �R Lr�AN '1.c3 -q 5.1-Co 050
(The individual to receive and MAILING ADDRESS E-MAIL
respond to all correspondence 1St,. at+N't'i444 IZO SV ATE - L MA-re e r/Rf3y3TEw!S 1✓L- r fork
concerning this application) CITY SlATE ZIP FAX
13\c•C tc--- W 5`lW-11
NAME
PROJECT FINANCING 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 su claim),which may be made by any person, including the undersigned, and filed against the city,
but only where such claim arise ut of the reliance of the city, including its officers and employees, upon the accuracy of the
information supplied to th city part of this application.
SIGNATURE: DATE ii/V/5
PRINT NAME: M4/' C M(LMAA
Bulletin#100-January 1,2013 Page 1 of 3 k:AHandouts\Permit Application