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09-103599CITY OF Federal Way COMM(6b7TY DEVELOPMENT SERVICES 2517-835-2607• FAX 253-835-2609 trzuu_�" h"otlederahun u. corn 6PERMIT'#FM?FQPf-q6._PL DE EN FP APPLICATION / PROPERTY %w.1 y op SITE ADDRESS VY SUITE/UNIT # ZONING ASSESSOR'S TAX/PARCEL # P DQ.TECT �j 1�� ,1111 J . NAME OF PROJECT Q,41� �lJ G A4J)� � Av (Tenant or Homeowner Name) iTr f"T ! `"UILDING ❑ PLUMBING ❑ MECHANICAL TYPE OF PERMIT ❑ DEMOLITION ❑ ELECTRICAL ❑ ENGINEERING ❑ FIRE PREVENTION PROJECT DESCRIPTION Detailed description of work to be included on this permit only PEOPLE NAME� PRIMARY PHONES PROPERTY OWNER / �y- `/ c /11, f:&W I ,k_ �--. Q - % l 6 U MAILING ADDRESS, CITY, STATE, ZIP E 337/ 3 vfiD AW JjJ ��1'LA L- Gs;A-Lt W g f e. I q.;"h OWNER IS ALSO: E] CONTRACTOR APPLICANT F] PROJECT CONTACT NAME PRIMARY PHONE /V ZA ( ) - MAIL NG ADDRESS, CITY, STATE, ZIP FAX CONTRACTOR WA STATE CONTRACTOR'S LICENSE # EXPIRATION DATE FEDERAL WAY BUSINESS LICENSE # NAME '\ M O AJ/ AJ /� PRIMARY PHONE (� 6) / 7 q- 4/ APPLICANT MAILING ADDRESS, CITY, STATE, ZIP 33 i 3ZNo ^Z_ 57,7 Q'Is�-t. tAAl WA FAX ,�Pr) 49 - SY6 PROJECT CONTACT NAME /J�� A4©,J!,)�-' "`�� PRIMARY PHONE 433 (The individual to receive and (��) ( / - MAILING ADDRESS, CITY, STATE, ZIP yy-� 3 3 1 3 )_ � ,SiJ > G(Je�- (,J WA- r yy FAX �y -7 (�u�1 )�J q _.� `,_ respond to all correspondence concerning this application) ALTERNATE CONTACT NAME: PRIMARY PHONE h E-MAIL C `I ai (�G) 60 - 71(f PROJECT FINANCING NAME OWNER -FINANCED Required for projects with MAILING ADDRE , CITY, STAT IP PRIMARY PHONE value of $5, 000 or more (RCW 19.27095) ( ) 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 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 'ty as a part of this application. A SIGNATURE: 8 I DATE �71 y� PRINT NAME: Bulletin 4100 - 8/28/2009 Page 1 of 4 k:AHandouts\Permit Application