18-1032364%
► PERMIT APPLICATION
CITY OF
Federal Way PERMIT CENTER + 33325 81h Avenue South + F deral Wa WA 98003-6325
253-835-2607 + FAX 253-835-2609 + ermit c a .Com
6-0
PERMIT NUMBER (0_ 1 l J U L 2 3 2018
TARGET DATE Q4r1C FEDEPAL
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SITE ADDRESS SUITE/U T #
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PROJECT VALUATION
ZONING
ASSESSORS TAX/PARCEL # /'
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TYPE OF PERMIT
❑ BUILDING ❑ PLUMBING ❑ MECHANICAL ❑ DEMOLITION ❑ ENGINEERING 1A FIRE PREVENTION
NAME OF PROJECT
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PROJECT DESCRIPTION
Detailed description of work to
be included on this permit only
NAME
PRIMARY PHONE
MAILING ADDRESS
E-MAIL
PROPERTY OWNER
CITY
STATE
ZIP
NAME
PHONE
MAILING ADDRESS hueE-MAIL
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CONTRACTOR
CITY*Tl"
S E
ZIP �
FAX
WA STATE CONTRACTOR'S LICENSE #
EXPIRATION DATE
FEDERAL WAY BUSINESS LICENSE #
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NAME Q
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PRIMARY PHONE
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MAILING ADDRESS
E-MAIL
APPLICANT
CITY\6M4STATE
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ZIP � I
FAX
NAME `
PRIMARY PHONE
PROJECT CONTACT
\
MAILING ADDRESS
E-MAIL
(The individual to receive and
respond to all correspondence
CITY
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STATE
cuA
ZIP
a o3
FAX
concerning this application)
PROJECT FINANCING
NAME
❑ OWNER -FINANCED
When value is $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. 1 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.
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SIGNATURE: DATE 1
PRINT NAME:
Bulletin #100 - January 29, 2016 Page 1 of 2 k:\Handouts\Permit Application
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