18-104913RECEIVED
CITY OF VAA:-PERMIT APPLICATION
OCT
18 2018 PERMIT CENTER + 33325 8th Avenue South + Federal Way, WA 98003-6325
Federal Way CITY OF FEDERAL WAY 253-835-2607 + FAX 253-835-2609 + permitcenter@cityoffederalway.com
COMMUNRY DEVELOPMENT
PERMIT NUMBER _ _ L? Ia -L3- _ 1�
TARGET DATE
SITE ADDRESS
�o 1v f-,6 e (oA \�a \47k'AwD-�)
SUITE/UNIT #
PROJECT VALUATION
ZONING
ASS R'S TAX/PARCEL #
$Nftf ).Ob
42- b- a J_ 0 -
TYPE OF PERMIT
❑ BUILDING ❑ PLUMBING ❑ MECHANICAL ❑ DEMOLITION ❑ ENGINEERING IRE PREVENTION
NAME OF PROJECT
PROJECT DESCRIPTION
~�
)
Detailed description of work to
be included on this permit only
NAME
PRIMARY PHONE
a
PROPERTY OWNER
MAILIx ADDRESS
w
E-MAIL
CITY
ST TE
NAME
HONE
`
MAILING ADDRESS.S
�
✓ti e
CONTRACTOR
CITY -
STATE
IP
'
FAR ry � V
a aL
A STATE CONTRACTOR'S LICENSE #
JWIRAfION DATE
FEDERAL WAY BUSHMS LICENSE #
NAME
PRIMARY PHONE
MAILING ADDR S
Ye
L
If a
APPLICANT•
CI 8 A E IP
FAR U/h Y
PROJECT CONTACT
NAME
C
PRIMARY PHONE
NAMING ADDRESS `/
n9Z_ 'l
L
(The individual to receive and
respond to all correspondence
concerning this application)
CITY STATE iP
FAX
xv 1
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 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 city as apart of this application.
I �
SIGNATURE: DATE kOl1 11 tb
PRINT NAME•
Bulletin #100 —January 29, 2016 Page 1 of 2 k:\Handouts\Permit Application