18-104899r
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CITY OF
Federal Way
PERMIT NUMBER ) 9 _
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PERMIT APPLICATION
OCT 17 2018 PERMIT CENTER + 33325 811, Avenue South + Federal Way, WA 98003-6325
UTY OF FEDERAL wAy 253-835-2607 + FAX 253-835-2609 + permitcenter@cityoffederalway.com
COMMUNFrY DEV OpMENT
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TARGET DATE T
SITE ADDRESS
SUITE/UNIT #
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Y
PROJECTVLUATION
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ZONING
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ASS SOR'S TAX/PARCEL #
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TYPE OF PERMIT
❑-1PLUMBING ❑ MECHANICAL ❑ DEMOLITION ❑ ENGINEERING 4 FIRE PREVENTION
El BUILDING
NAME OF PROJECT
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PROJECT DESCRIPTION
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Detailed description of work to
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be included on this permit only
NAME
PRIMARY PHONE
PROPERTY OWNER
MAILING ADDRES
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ITY
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HONE
MAILING ADDRESS
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CONTRACTOR
CITY
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WA STATE CONTRA OR'S LICENSE #
EXPIRATION DATE
FEDEP.AL WAY BUSINESS LICENpSEE #
NAME
PRIMARY PHONE
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MAILI G ADDRESS _ i�
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APPLICANT
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CITY
STATE
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NAME`�
PRIMARY PHONE
PROJECT CONTACT
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(The individual to receive and
respond to all correspondence
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concerning this application)
PROJECT FINANCING
NAME
❑ OWNER -FINANCED
When value is $5,000 or more
MAILING ADDRESS, CITY, STATE, ZIP
PHONE
(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 city as apart of this application.
SIGNATURE: to I DATE
PRINT NAME:
Bulletin #100 — January 29, 2016 Page 1 of 2 k:\Handouts\Permit Application