18-104868RECEIVED PERMIT APPLICATION
CITY OF
OCT 1 b 2018 PERMIT CENTER + 33325 8� Avenue South + Federal Way, WA 98003-6325
Federal Way 253-835-2607 + FAX 253-835-2609 + permitcenter@cityoffederalway.com
CITY OF FEDERAL WAY
COMMUNffY DEVELOPMENT �J
PERMIT NUMBER 8 _ V / S- - TARGET DATE
SITE ADDRESS
SUITE/UNIT #
r
L(J� O
PROJECT VALUATION
ZONING
ASSESSOR'S TAX/PARCEL #
$ 2-
z t 5 q( S_ 0 0 i O
t%CD
TYPE OF PERMIT
1:1 BUILDING El PLUMBING El MECHANICAL El DEMOLITION ❑ ENGINEERING FIRE PREVENTION
NAME OF PROJECT
-VAkIO
L l
PROJECT DESCRIPTION
'
Detailed description of work to
V c
be included on this permit only
NAME
5derl;n 12e�cl d r C
PRIMARY PHONE
PROPERTY OWNER
MAILING ADDRESS
E-MAIL
rol AVP 5
.3-2-001
CITY` t
F o -oe n`yVl1 wLl
STATE
ZIPq
NAME yy�p
PHON4 _
MAILING ADDRESS
UA
E-MAIL
CONTRACTOR
2
C
STATE
ZIP
FAX
�L(
W�► STATE CONTRACTOR'S LICENSE #
EXPIRATION DATE
C
FEDERAL WAY BUSINESS LICENSE #
�7�000
j q
NAME
rE-
PRIMARY PHONE
-Wl3 -- r ZY 4d
re ,vv�
MAILING ADDRESS
E -Mn
i
APPLICANT-
STATEZIP
W ,JIj
^�
l�
FAX �/fir , cx'—
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 MAILING ADDRESS, CITY, STATE, ZIP PHONE
(RCW 19.27 095)
I certify under penalty ofperjury 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 Iocal, state, or federal laws regulating
construction or en onmental laws.
I further agn. hold harmless the City of Federal Way as to any claim (including costs, expenses, and attorneys' fees incurred in
the investigation defens f such claim), which may be made by any person, including the undersigned, and filed against the city,
but only where h claim ses out of the reliance of the city, including its officers and employees, upon the accuracy of the
information su Ii d tot as apart of this application.
II�
SIGNATURE: DATE
PRINT NAME:
Bulletin #100 -January 29, 2016 Page 1 of 2 k:\HandoutsTermit Application