13-102830 • IP
CRY OFA PERMIT APPLICATION
Federal Way RECEIVED
PERMIT NUMBER I ✓ - I O 0 V 0 .t . JUN 2-6 2013
— — — — TARGET DATE CITY OF FEDERAL WAY
SITE ADDRESS SUITE/
I`Io5 s Sitstin. S41- f4A4.4-6.1 V" r \A ctsv0'3
PROJECT VALUATION ZONING ASSESSOR'S TAX/PARCEL#
$ 3, d <v • nc> - — — — —
TYPE OF PERMIT 0 BUILDING 0 PLUMBING ❑ MECHANICAL ❑ DEMOLITION ❑ ENGINEERING 'FIRE PREVENTION
NAME OF PROJECT SDp{'t S"."..5 A.,) 041.hit _ r
PROJECT DESCRIPTION 3 "500-t- G O sew k..e 4..., G auf- CI) 1,tin, /SKub -
Detailed description of work to +L) -e-- bl; S'f 4 $' '
be included on this permit only J
NAME PRIMARY PHONE
PROPERTY OWNER S 733- 8$5-44‘00po�}S MA.►�S �'K.�'s'C.
MMAkING o 5 ADDRESS }% E-MAIL
STATE ZIP
o f .7, W Al a to03
NAMEPHONE
11......4...4,.. /4L.4.1.4 14.5-4 71 -3A tz
MAILING ADDRES 1 E-MAIL
CONTRACTOR 591 11 Of 4 S W
C STAT ZIP FAX
ilea•0.- W A 944 67 tis,-'173 - K 551-
WA STATE CONTRACTOR'S LICENSE# EXPIRATION DATE FEDERAL WAY BUSINESS LICENSE#
MO tAnYtA4(166 Pfc ►o / S / Itl 7.4-05-loosutt-00-et-
NAME PRIMARY PHONE
ti.tsr...+g.-;„. A10•-l1^' 1s3 -K73 -3*I7
APPLICANT
MAILING ADD� ` E-MAIL
SA 11 b«h-A41 54. \'')
TY
( FAX
1000,01.,/.... STATE 44'46Z )-'113-' 551.
N PRIMARY PHONE
PROJECT CONTACT S c•G-.1 1.51 -t17 3 - 3 S:rt*
(The individual to receive and CMAIL G ADD S 1 �) E-MAIL
respond to all correspondence T'I( O(G"KC 5t "" 4#t+nSs,Av MARwa..
concerning this application) QTY STATE ZIP FAX
,r53.14-73 - k fSZ
NAME
PROJECT FINANCING 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 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 city as a part of this application.
SIGNATURE: DATE 6/2.-S I % '3
PRINT NAME: 6- G" S-t..."‘
Bulletin#100-January 1,2013 Page 1 of 3 k:\Handouts\Permit Application