12-103195arr or
Federal Way
COMMUNITY DEVELOPMENT SERVICES
253-835-2607• FAX 253-835-2609
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PERMIT D ECEIVEf MF
APPLICATION
JUL 112012
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SITE ADDRESS0, W CDS%
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SUITE/UNIT #
PROJECT VALUATION
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ASSESSOR'S TAX/PARCEL#
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TYPE OF PERMIT
❑ BUILDING ❑ PLUMBING ❑ MECHANICAL
❑ DEMOLITION ❑ ENGINEEIPNG FIRE PREVENTION
NAME OF PROJECT
(Tenant Name/Homeowner Last Name)
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PROJECT DESCRIPTION
Detailed description of work to
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be included on this permit only
PROPERTY OWNER
NAME PRIMARY PHONE
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MAILING ADD S rO +1\ /wV'
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E-MAIL
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CLQ 1 STATE ZIP �� p,
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CONTRACTOR
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ZIP
FAX
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EXP/TON % T
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FEDERAL WAY BUSINESS LICENSE #
NAME
PHONE
APPLICANT
MAILING ADDRESS
E-MAIL
CITY STATE ZIP
FAX
PROJECT CONTACT
(The individual to receive and10
respond to all correspondence
concerning this application)
NAME
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MAILING ADORES
ryME M'Ar�II
CITY
STATE
ZIP
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FAX 0\W`�
ALTERNATE CONTACT NAME:
PHONE
E-MAIL
PROJECT FINANCING NAME
_..__....._..........__ � OWNER -FINANCED
............
Required value of $5,000 or more
(RCW 19.27.095) MAILING ADDRESS, CITY, STATE, zn-, .-_.. _..., PHONE
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 Ci of Federal Way as to any claim (including costs, expenses, and attorneys' fees incurred in
the investigation and deq&ense of ch cla , which maybe made by any person, including the undersigned, and fi ed against the city,
but only where such cl aris out f the reliance of the city, including its officers and employees, ' pon he accuracy of the
information supplied to city a p of this application. 1
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SIGNATURE: DATE
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PRINT NAME: UU-z) v v _
Bulletin #100— January 1, 2011
Pagel of 3
k:\Handouts\Permit Application
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