13-100436 RE•IVED •
CITY OF IAN 29 2013 PERMIT APPLICATION
Federal Way
CITY OF FEDERAL WAY
CDS
PERMIT NUMBER 3 _ _( 6 a 4 % o
/// TARGET DATE
SITE ADDRESS SUITE/UNIT#
Soi�Iry --3 y yTH 4T, rePeR9t_ w,4y , w/
PROJECT VALUATION ZONING ASSESSOR'S TAX/PARCEL# _
$ 12oo ,00 ,
Cr02
TYPE OF PERMIT 0 BUILDING 0 PLUMBING 0 MECHANICAL 0 DEMOLITION 0 ENGINEERING,®FIRE PREVENTION
NAME OF PROJECT 6- ��f3g tu 58 50;,rrH
PROJECT DESCRIPTION
iQ 6.M01�3N i 5/'7o/c L' 17e-T eL7-s� a v0 1-1oR 4//sTeoc e.
Detailed description of work to
be included on this permit only
NAME PRIMARY PHONE
PROPERTY OWNER w ',/tR/4A E U 5 erg 4:
MAILING ADDRESS E-MAIL
'2"83s' , 14TH yNTf/ ,TIS�L�T
CITY STATE ZIP
FfiDLR4 is Iry AY W A %$oo 3
NAME PHONE
PigOwJGrI =/✓L. o --s-7r 031f
MAILING ADDRESS E-MAIL
CONTRACTOR 107 wA s H yN /1 c,vo
CITY STATE ZIP FAX
AAA w/9 0$oo 253-'7'33=y476
WA STATE CONTRACTOR'S LICENSE# EXPIRATION DATE FEDERAL WAY BUSINESS LICENSE
r R(foI OggKw S"/ 1 13-7.6 -0/-�a2a94-x-13`_
NAME PRIMARY PHONE
APPLICANT MAILING ADDRESS E-MAIL
CITY STATE ZIP FAX
NAME PRIMARY PHONE
PROJECT CONTACT Lr vim,/ Rd 3,2N S lob-5-75--0111
(The individual to receive and MAILING ADDRESS E-MAIL
respond to all correspondence (C 7 U1',5 f'=/VG To N LVD
concerning this application) CITY STATE ZIP FAX
A-t.&() t�.�} C7 ,O l Zs3-73c-y976
PROJECT FINANCING NAME 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 authorised 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 Wag regulations pertaining to the work authorised 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 o� of the city, including its officers and employees, upon the accuracy of the
information supplied to the city as a •• - � ation.
,iø,
SIGNATURE: , —ask.._ DATE 1 1A 111
PRINT NAME:
Bulletin#100—January 1,2013 Page 1 of 3 k:\Iandouts\Permit Application