10-103005o der ECEI�V ERMI , {� King *1re9&
COMWIJNITYDEVELOPMENTSERMESJUL 1 5A''FLICA (aN Approved
5.3
2-8.35-2607• FAX 253-835-2609
n•ua:__iu�ejerig.a{u_ay, cern _ etailed
_
CITY OF FEDERAL WAY 'VSubject to attached details
-_-36)05
CO ME PL DE EN FP
Rescue
SITE ADDRESSCDS
SUITE/UNIT #
0 21 /�i.L 5 -IA/ Date a 02 0
PROJECT VALUATION
ZONING
ASSESSOR'S TAX/PARCEL #
$ l2C-> U
-- -- — — -- —
TYPE OF PERMIT
❑ BUILDING ❑ PLUMBING ❑ MECHANICAL
❑ DEMOLITION ❑ ENGINEERING IIZE PREVENTION
NAME OF PROJECT
(Tenant Name/Homeowner Last Name)
e s L 1
PROJECT DESCRIPTION
Lo A,0
Detailed description of work to
be included on this permit only.
PROPERTY OWNER
NAME
O Y O
PRIBART PHONE
MAEUNG ADDRESS - -
E-MAIL,
CITY
STATE
ZIP
NAME
r
PHONE
C 2fj 2
MAILING ADDRESS
ftp l
E-MAIL
CONTRACTOR
CITY
STATE
FAX 253 �3� Q
WA STATE MR" I CTOR'S LICENSE #
EXPIRATION DATE
PEDEML VAT BDSUMS LICENSE #
NC
PHONE
2v6-22 2
MAILING ADDRESS
:;::"/6 .-
E-MAIL
APPLICANT
CITY
STATE
Ll
FAX
PROJECT CONTACT
NAME If
PHONE
(The individual to receive and
MAIIJNG ADDIda
respond to all correspondence
concerning this application)
CITY
STATE
ZIP
910
FAX
ALTERNATE CONTACT NAME:
PHONE
Z-MAiL
PROJECT FINANCING
aAnag
OWNER -FINANCED
Required value of $5, 000 or more
MAILING ADDRESS, CITY, STATE, ZIP
PHONE
(RCW 19.27.095)
I certib under penalty of perfury that I am the property owner or authorized agent of the properly 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. 1 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:g _ DATE
PRINT NAME �✓ /t Y? I� Cox ! it d
Bulletin #100 - April 14, 2010 Page I of 3 k:\Handouts\Permit Application