18-104282i LULIVE®
SEP 13 2018 PERMIT APPLICATION
CITY OF V;N&
CITY OF FEDERAL WAY PERMIT CENTER + 33325 8th Avenue South + Federal Way, WA 98003-6325
Federal Way COMMUNMY DEVELOPMENT 253-835-2607 + FAX 253-835-2609 + permitcenter@cityoffederalway.com
PERMIT NUMBER / x - - _Z 0 y � S_ A - FP
vv TARGET DATE
SITE ADDRESS
SUITEMNIT #
2010 -3w 35b -T14 %.r FEDEa4L VV 4`I / WA
PROJECT VALUATION
$ 0JO/OOO, 00
ZONING
ASSESSOR'S TAR/PARCEL #
A s A _Z ® 3—
TYPE OF PERMIT
❑ BUILDING ❑ PLUMBING ❑ MECHANICAL ❑ DEMOLITION ❑ ENGINEERING FIRE PREVENTION
NAME OF PROJECT
14 o rmsW F -a S'M ap&s-.
PROJECT DESCRIPTION
ur Vec c 'M . o� oK
Detailed description of work to
izlfti- 104 S f leer .
be included on this permit only
NAME
PRIMARY PHONE
6111 VIK
253- 301q --'F► D
PROPERTY OWNER
MAILING ADDRESS
B$01 W vm w --*-lbl
E -MAH.
CITY
�vevQ►i
STATE I
WA
ZIP
`Z180m
NAME
PHONE
MAILING ADDRESS�
1 Sb D l W VA\ -LC 1lwY Pl 4-1t.1
E-MAIL
CONTRACTOR
CITY
vFvvu►
STATE
WA
ZIP
a $ oo�
FAX
WA STATE CONTRACTOR'S LICENSE #
EXPIRATION DATE
FEDERAL WAY BUSINESS LICENSE #
NAME *Q�, ,,��
WMA
PRIMARY PHONE
n
MAILING ADDRESS
1512- RAJ � AVE
E-MAIL
APPLICANT-
%NA GovT. . �$'
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FAX
1LA&t
TWETSG®b3 Oct .
PROJECT CONTACT
NAME
Z—vLem
PRIMARY PHONE
V53r %q0
MAMmG ADDRESSE
M21 17-ew "_
MAn
a � 1 �" ' - fA�"
(The individual to receive and
respond to all correspondence
CITY
Svw+rlve-
STATE
ZIP
9
FAX
concerning this application)
PROJECT FINANCING
NAME
❑ OWNER -FINANCED
When value is $5,000 or more
(RCW 19.27.095)
MAILING ADDRESS, CITY, STATE, ZIP
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 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 apart of this application.
SIGNATURE: .� DATE
PRINT NAME:.�
Bulletin #100 -January 29, 2016 Page 1 of 2 k:\HandoutslPermit Application