16-104625CITY OF
Federal Way
PERMIT NUMBER i,
( _ 1 O 4 6 Z -
PERMIT APPLICATION
PERMIT CENTER + 33325 81h Avenue South + Fed 98003-6325
253-835-2607 + FAX 253-835-2609 + permitcent 'ay.com
SEP 16 2016
SITE ADDRESS(
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SUITE/UN 8
gWECT VALUATIONZONING
ASSESSOR'S TAR/PARCEL S
TYPE OF PERMIT
❑ BUILDING ❑ PLUMBING ❑ MECHANICAL ❑ DEMOLITION [--]ENGINEERING FIRE PREVENTION
NAME OF PROJECT
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PROJECT DESCRIPTION
Detailed description of work to
be included on this permit only
NAME t
r ICU LLC
PRIMARY PHONE
PROPERTY OWNER
MAILINGS ADDRESS
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E-MAIL
CITY
STATE
ZIP
NAME
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MAILING ADDRESS 1
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E-MAILMMA
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CONTRACTOR
CITY STATE
r `10P,
ZIP
a 223
FAX
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WA SATE ... RA O 'S_ I,ICENS
EXPIRATION DATE
FEDERAL WAY BUSINESS LICENSE M
PRIMARY PHONE �_0
APPLICANT
MAILING ADDRESS
E-MAIL
CITY
STATE
ZIP
FAX
N
PRIMARY PHONE
PROJECT CONTACT
MAILING ADDRESS
EMAIL
(The individual to receive and
respond to all correspondence
CITY STATE ZIP
FAX
concerning this application)
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 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 clairN, 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 a part of this application.
A A nr
SIGNATURE: DATE
PRINT NAME: li•
Bulletin #100 — January 29, 2016 Page I of 2 k:\Handouts\Permit Application