15-100027My OF V&
Federal Way
PERMIT NUMBER J -
WCEMM
PERMIT*APPLICATION
JAN 05 2015
CITY OF FEDERAL WAY
O jDr ) — FP TARGET DATE
STT EADDRE88 SUITE/UNIT 0
PR VALUATION ZONING ASSESSOR' TAR PARCEL i
$ �2
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TYPE OF PERMIT
❑ BUILDING ❑ PLUMBING ❑ MECHANICAL ❑ DEMOLITION ❑ ENGINEERING FIRE PREVENTION
NAME OF PROJECTe62a&—),--j
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PROJECT DESCRIPTION
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Detailed description of work to
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be included on this permit only
NAME
PRMIARY PRONE
PROPERTY OWNER
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MATTING" S
FAXAH,
CITY
STATE
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PHONE
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E-MAIL
CONTRACTOR
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DATE
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NAME d�//''m�
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APPLICANT
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MAILING11
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CITY
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ZIP
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NAME Q�
ONE
PROJECT CONTACT
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(The individual to receive and
respond to all correspondence
CITY I
STATE
7PP
FAX
concerning this application)
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PROJECT FINANCING
MME
OWNER -FINANCED
Required value of $5, 000 or more
NG ADDRESS, CITY, STATE, ZIP
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(RCW 19.27.095)
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I certify under penalty of perjury that I am the property owner or authorized agent of the property owner. I cert(ty 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 cl arises out of the reliance of the city, including its officers and employees, upon the accuracy of the
information supplied t e Citli as apart of this application.
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SIGNATURE: DATE
PRINT NAME:
Bulletin #100 — January 1, 2013 Page 1 of 3 k:\Handouts\Permit Application
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