13-103582r '
CITY of ,
Federal Way
PERMIT NUMBER / I _
PERM I'6APPLICATION
Q o o ROVED RECEIVE®
AUG 1 013
/ 10 -5 - P TARGET DATE
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SITE ADDRESS
SUITE/UNIT #
PROJECT VALUATION
ZONING
ASSESSOR'S TAR ARCEL #
TYPE OF PERMIT
❑ BUILDING ❑ PLUMBING ❑ MECHANICAL ❑ DEMOLITION ❑ ENGINEERING FIRE PREVENTION
NAME OF PROJECT
PROJECT DESCRIPTION
Detailed description of work to
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C`C C c--! t`^ ��'•� c
be included on this permit only
PROPERTY OWNER
NAME \ PRIMARY PHONE
T1 S 5� 1 " U
MAIL ADDRESS
�. C l
E-MAIL
CITY STATE ZIPn
1�cl�a_r i. � c
NAME
PHONE
MAILINT ADDRESS
E-MAIL
CONTRACTOR��
CITY
STATE
ZIP
FAX
WA STAGE TRACTOR'S LICENSE # EXPIRATION DATE
FEDERAL WAY BUSINESS LICENSE #
NAME .
PRIMARY PHONE pp
MAIL NG ADD S
E-MAIL
APPLICANT
CITY �. STA)TE ZIP f
F�
PROJECT CONTACT
NAME
PRIMARY PHONE
MAILI
G ADDRESS `
. ` ` \
E-MAIL
(The individual to receive and
respond to all correspondence
CITY /ny . STATE ZI��
T 1 ,. G , r` --.ice- 1 '7 �i �1 l�ti \
FAX y
.. .'-) 'S J - `" ) / l.-_:
concerning this application)
PROJECT FINANCING
NAME
E]OWNER-FINANCED
Required value of $5, 000 or more
(RCW 19.27095)
MAILING ADDRESS, CITY, STATE, ZIP
PHONE
I cert(& under penalty of perjury that I am the property owner or authorized agent of the property owner. 1 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
fence of such claim), which may be made by any person, including the undersigned, and filed against the city,
but only whuch aim arises out the reliance of the city, including its officers and employees, upon the accuracy of the
the* stga4lied
information to he city asap of this application.
SIGNATURE: t �- C/ DATE
PRINT NAME:
Bulletin #100 —January 1, 2013 Page 1 of 3 kAliandouts\Pelmit Application