18-10469040k
CITY OF
Federal Way
RECEIVED
OCT 0 4 2018 PERMIT APPLICATION
CITI� OF FEDERAL WAYERMIT CENTER + 33325 8th Avenue South + Federal Way, WA 98003-6325
COCffY (FY DEVELOPMENT253-835-2607+ FAX 253-835-2609 + permitcenter@cityoffederalway.com
PERMIT NUMBER
TARGET DATE
SITE ADDRESSSUITE/UNIT
#
o 67 s 3-2-0� 5t- d� n �'
- (c) Ct
PROJECT VALUATION
$
ZONING
ASSESSOR'S T /PARCEL #
-3a-7-300-06a0
TYPE OF PERMIT
❑ BUILDING ❑ PLUMBING ❑ MECHANICAL ❑ DEMOLITION ❑ ENGINEERING IRE PREVENTION
NAME OF PROJECT
�W CIA10, "%S c
a `
PROJECT DESCRIPTION
Detailed description of work to
be included on this permit only
NAME
PRIMARY PHONE
Seo e D n
e -o 1,1
PROPERTY OWNER
MAILING ADDRESS
E-MAIL
CITY
STATE
ZIP
NAME
eco tic: - C, Z.1 c
PHONE
MAILING ADDRESS
2 l 3 �d
E-MAIL
U 56
CONTRACTOR
CITYSTA
�e ���
E
pa
ZIP /�
as
FAX /
WA STATE CONTRACTO S LICENSE #
W(5-La6S �b
EXPIRATION DATE
FEDERAL WAY BUSINESS LICENSE #
NAME
�� v e
PRIMARY PHONE
x 9 9,9 V
MAILING ADDRESS
E-MAIL
APPLICANT-
CITY
STATE
ZIP
FAX
NAME
PRIMARY PHONE
PROJECT CONTACT
MAILING ADDRESS
E-MAIL
(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
(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 cert(& 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 0
PRINT NAME:. -
Bulletin #100 — January 29, 2016 Page 1 of 2 kAHandouts\Permit Application
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