18-104489® RECEIVE®
C,noF PERMIT APPLICATION
S6C 2 2018
P 1 PERMIT CENTER + 33325 81h Avenue South + Federal Way, WA 98003-6325
Federal Way CITY OF FEDERAL WAY 253-835-2607 + FAX 253-835-2609 + permitcenter@,cityoffederalway.com
COMMUNITY DEVELOPMENT
PERiY{IT Nu=ER _ ® 7 Q� _ -
�L ��LL —.0 L TARGET DATE
SITE ADDRESS
SUITE/UNIT #
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13
PROJECT VALUATION
ZONIIN ASSESSOR'S TAR/PAR L #
p
TYPE OF PERMIT
❑ BUILDING ❑ PLUMBING ❑ MECHANICAL ❑ DEMOLITION ❑ ENGINEERING VFIRE PREVENTION
NAME OF PROJECT
7-k �eC-
PROJECT DESCRIPTION
Detailed description of work to
be included on this permit only
NAME
PRIMARY PRONE
PROPERTY OWNER
ING ADDRESS \
MAA.
ITY
STATE
AME
PHONE
OtAIUNG ADDRESS
�
MAIL
a
CONTRACTOR
CjTy
9�f
FAX
A STATE CONTRACTOR'S LICENSE #
EXPIRATION DATE
FEDERAL WAY BUSINESS LICENSE #
NAME -� �e
Va
MIA
PHONE'
l(
MAILING ADDRE"
MAD,
2
APPLICANT-
SUTE
FAX
� �l
NAME
PRUmay PHONE
PROJECT CONTACT
�(
G ADDRESS
�e
(The individual to receive and
respond to all correspondence
ITY
STATE
FAX
concerning this application)
C�l r
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 authorised 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 ciair4 which may be made by any person, including the undersigned, and flied 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
irgjormation supplied to the city as apart of this application.
SIGNATURE: `C DATE
PRINT NAME. Y
Bulletin #100 — January 29, 2016 Page 1 of 2 k:\Handouts\Permit Application