18-104633` RECEIVED
CITY OF � PERMIT APPLICATION
OCT 01 2018 PERMIT CENTER + 33325 8th Avenue South + Federal Way, WA 98003-6325
Federal Way 253-835-2607 + FAX 253-835-2609 + permitcenter@cityoffederalway.com
CITY OF FEDERAL WAY
COMMUNITY pEVE1.OPMENi',
PERMIT NUMBER —Z I _ L a -V— /w— 3- _ 4E119 TARGET DATE
SITE ADDRESS
A d , ,:,:: 2� XZ � 5
SUITE/UNIT #
PROJECT VALUATION/v'�
ZONING
ASSESSOR'S TAX/PARCEL # /� n �%
TYPE OF PERMIT
❑ BUILDING ❑ PLUMBING ❑ MECHANICAL ❑ DEMOLITION [--]ENGINEERING FIRE PREVENTION
NAME OF PROJECT
PROJECT DESCRIPTION
Detailed description of work to
be included on this permit only
NAME
PRIMARY PHONE
PROPERTY OWNER
MAILING ADDRESS
E-MAIL
CITY
STATE
ZIP
NAME
PHONE
CONTRACTOR
MAILING ADDRESS 516 %
l /L — 1
E-MAIL
CITY
TA
/
FAX
WA STATE CONTRA TOR''S LICENj9E #
, V/
EXPIRATION DATE
FEDERAL WAY BUSINESS LICENSE #
NAME
PRIMARY PHONE
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 cera& 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 , which may be made by any person, including the undersigned, and filed against the city,
but only where such claim aris o of reliance of the city, including its officers and employees, upon the accuracy of the
information supplied to the ci p of this application.
r
f�
SIGNAT DATE
PRINT N E:�D
Bulletin #100 — January 29, 2016 Page 1 of 2 k:\Handouts\Permit Application