15-104592RECEII/ft
cer,or ',�*�,�►._.. sEP 0 2a PERMIT
Federal "Y OF FEDERA
° 25 o7= -M SDs "PLICATION
ry LcALuoWdoWwau.mm
•
lE; -1 o 4.59 2 -
SF MF CO ME PL DE EN&
Sr= ADDRESS
SOITE/11Nir •
35724 4th place sw
PROJECT VAL"MON
LORM
ASSESSOR'S T" PAR= i
3,800.00
_ 302104-9180
TYPE OF PERIDT
❑ Sura IG ❑ PLAMMMWG ❑ IWDCHANICAL
❑ DEMOLITION ❑ ZNGDMRiNG X FM PREVENTION
NAME OF PROJECT
aWusttName/HomemmerLust Name1
Ford residence
PROJECT DESCRIPTION
Detailed description of work to
be &wb.Wed on dVs pear& only
PROPERTY OWNER
NAPE
Hm1ARY PROBE
YAD.DIG ADDRESS
E ---�
CIT(
MA79 I
LIP
mmo Evergreen Fire Protection, Inc.
room 253-252-7942
CONTRACTOR
YA=GAnnm" PO Box 998
Evergreenfirepro@msn.com
tny PuyallupWa
' 98371
WA STATE COMRAC1'OR'S LN=N8E
Ever f 967lz
EXPIRATION DATE
6/ 8 /201
FsnERAL WAY EDSn1E861JCENSE e
20-05-106411-OOBL
14`M same as above
APPLICANT
WARMG ADDRESS
tFYAII
Cm
STATE
Lip
FAX
� (ANT
NAM Mike Hutchinson
m*NE 253-381-4456
recekv and
YAJUNG AWVZW
R.YAIL
Evergreenfireproomsn.co
respond to all QOrrespander"
concentbW Hiss applicatioN
Cm
STATS
LIP
FAX
AUMMIMOOKrAM NAYS:
PRONE
WKAD.
PROJECT FINANCING
NAM
❑ OWl(EIt-FIIfAIiCED
Requ&ad Lnlue of $5,000 or more
YAII,NIG ADDR . Mr. 8TAZL UP
l90N8
iRCW 19.27.0951
I oertW under penalty of perjury that I am the property owner or authorised agent of the property owner. I certify that to the beat
of mty knowledge, the information submitted in support of fids permit application is true and correct. I cw tVy that I will comply with
all applicable My of Pledered Way regulations pertaining to the work antfun iced by the issuance of a permit. I u nderstarrd that the
issuance of this permit does not remove the ounnees nuponsibility .%' compliance with local, state, or federal laws regulating
Construction or wivirommental laws.
I further agree to hold harmless the City of pbderal Way as to any claim (including costs, arpenses, and attorneys' fees incurred in
the investigation and dq*— of such da[W, which may be made by any person, including the undersigned, and f sled against the city,
but only where such claim arises out of the reliance of COW city, 6ncluding its g04cers and employees, upon the accuracy of the
information supplied to the city as a Pa of this application
SIGNATURE:OA�-i u DATE 9/9/2015
PRIM NAUX: Mike Hutchinson
Bulletin #100 — January 1, 2011 Page 1 of 3 kAHandoutsWermit Application
u