18-103284RECEIVED PERMIT APPLICATION
5 2018 PERMIT CENTER + 33325 81h Avenue South + Federal Way, WA 98003-6325
253-835-2607 + FAX 253-835-2609 + permitcenterLa;citvoffederalway.com
t C;I ,- i OF NFEDERAL WAY
Ci 61,y�UtF!TY DEVELOPMENT
PERMIT NUMBER _ �1 3 r� s�
TARGET DATE / — J' —18�
SITE ADDRESS
SUITE/UNIT #
0 0�qSD
TVIt 6-:nL,0-N
PROJECT VALUATION
$21376,0
ZONING
ASSES OR'S TAX/PARCEL #
7 0-7 q 2- 0 0 3
-5
TYPE OF PERMIT
❑ BUILDING ❑ PLUMBING ❑ MECHANICAL ❑ DEMOLITION ❑ ENGINEERING IRE PREVENTION
NAME OF PROJECT
Rb t,Fm T .1_.
r
PROJECT DESCRIPTION
Detailed description of work to
be included on this permit only
NAME
PRIMARY PHONE
PROPERTY OWNER
MAILING ADDRESS
E-MAIL
CITY
STATE
ZIP
NAMECOk
PHONE 621A
MAILING ADDRESS
bl5br,$
E-MAIL
,'y �(�
J` '
CONTRACTOR
CI l I e
$TA'1'W
W
ZIP
%`n
F
WA STATE CONTRACTOR'S LICENSE # EXPIRATION DATE
FEDERAL WAY BUSINESS LICENSE #
UAM
EIRV�Ic b �\eT� S\
MRY
PF J lNV✓
MAILING ADDRE I 1J
24 S • S-fi
E-MAIL
oar �fireki'to
APPLICANT
CIT STATE ZIP
``
FAX
NAME�,'p.y�
Man do a
PRIMARY PHONE
2(06' er-7 — 2A33
PROJECT CONTACT
w�
MAILING ADDRESS �s�-•
Z 5 f
E-MAIL
Ki
(The individual to receive and
respond to all correspondence
• V1•
A eerdem
CITY\STAl�1TE
Y VN
ZIP
FAX
•�
ConCel7ling 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. 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.
1 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 as apart of this application.
city
SIGNATURE: J ► �` ` 11\J �V/ `^ �J
DATE V
PRINT NAME: ��\ 1 \, o- mmvfv
L
Bulletin #100 — January 29, 2016 Page 1 of 2 k:\Handouts\Permit Application
rk-cm