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PERM I10APPLICATION
CITY OF
Federal Way
ee
SEP 1 +� Z��U
PERMIT CENTER + 33325 8� Avenue South + Federal Way, WA 98003-6325
—
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253-835-2607 + FAX 253-835-2609 + permitcenter cot cityoffederalway.com
PERMIT NUMBER / 0
CITY OF FEDERAL WAY
1 0 LfDb -
TARGET DATE,
SITE ADDRESS /,5+ hA)� Sw
SUITE/UNIT #
PROJECT VALUATION
$
)0100-0
ZONING
ASSESSOR'S TAX/PARCEL # � 0 �
3 2
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TYPE OF PERMIT
❑ BUILDING ❑ PLUMBING ❑ MECHANICAL ❑ DEMOLITION ❑ ENGINEERING E t IRE PREVENTION
NAME OF PROJECT
C VS %� ✓ 12 kn1-9 G
L)W I)` r C viy
PROJECT DESCRIPTION
Detailed description of work to
be included on this permit only
•
NAME
PRIMARY PHONE
C VS
PROPERTY OWNERMAILING
ADDRESS
E-MAIL
CITY
ZIP
�TSTATE
NAME 'ISG � f IV e W f� C /a nl ,V �. �C..�
PHONE
—
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MAILING ADDRESS
-S( 2 6� ��� Lt^ - Y r/� '0a 0
E-MAIL
sM."((to ✓2 C
CONTRACTOR
CITY
)'v, C)L IM S' l- CD
STATE
6H: c
ZIP
(4
FAX Cc'�"I
LG /L yG -c;
WA STATE CONTRACTOR'S LICENSE #
EXPIRATION DATE
FEDERAL WAY BUSINESS LICENSE #
NAME
PRIMARY PHONE
T o L)
c/ 90 71?
APPLICANT
MAILING ADDR S i
E-MAIL
CITY
GC to C fel)
STATE
�N o
ZIP
FAX
44 0 716 (1016
NAME
�0 C,
PRIMARY PHONE
PROJECT CONTACT
iY�/
MAILING ADDRESS
-�%� /✓ RA 1)(-6 P619D
E-MAIL
The individual to receive and
respond to all correspondence
CITYL I7'I
0
STATE
ZIP1
FAX
concerning this application)
A) _Q
PROJECT FINANCING
NAME
❑ OWNER -FINANCED
When value is $5,000 or more
MAILING ADDRESS, CITY, STATE, ZIP
PHONE
(RCW 19.29.095)
I certify under penalty of per}ury 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 1 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.
V
SIGNATURE:, ✓ DATE
/
PRINT NAME:
Bulletin #100 - January 29, 2016 Page 1 of 2 k:\Handouts\Permit Application
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