18-104994RECEIVED
Am PERMIT APPLICATION
CITY OF OCT 2 3 2018
Federal Way PERMIT CENTER + 33325 811, Avenue South + Federal Way, WA 98003-6325
CITY OF FEDERAL WAY 253-835-2607 + FAX 253-835-2609 + permitcenter@cityoffederalway.com
COMMUNITY DEVELOPMENT
PERMIT NUMBER I (� _ ' V y y _ TARGET DATE / "!
SITE ADDRESS
SUITE/UNIT #
PROJECT VALUATION
ZONING
ASSESSOR'S TAX/PARCEL #
$ 2�
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TYPE OF PERMIT
❑ BUILDING ❑ PLUMBING ❑ MECHANICAL ❑ DEMOLITION ❑ ENGINEERING -EA FIRE PREVENTION
NAME OF PROJECT
'
PROJECT DESCRIPTION
Detailed description of work to
A VVr t yk J f >1
C o> Y-1 p.O d
be included on this permit only
NAME
PRIMARY PHONE
PROPERTY OWNER
MAILING ADDRESS
E-MAIL
CITY
STATE
ZIP
c � C n2
0 L
PHONE
or-)
LING AD SS
0 X , C h C' ,
E-MAIL
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CONTRACTOR
CITY
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STATE (
�
ZIP
QnI—
FAX
WA STATE CONTRACTOR'S LICENSE #
� c c)C,
4XPIRATION DATE
` 31
FEDERAL WAY BUSINESS LICENSE #
- I<- 0 2
N E
PRIMARY PHONE
20 b - cl)
APPLICANT"--
MAILING ADDRESSE-rL
TY
STAT
Z
FAX
PROJECT CONTACT
NAME �•
PRIMARY PHONE
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 19.27095)
MAILING ADDRESS, CITY, STATE, ZIP
PHONE
I cert(& 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 cert(& 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.
1 further agree to hold harmless the City of Federal W as to any claim (including costs, expenses, and attorneys' fees incurred in
the investigation and defense of such claim), which may ade by any person, including the undersigned, and filed against the city,
but only where such claim art out of t reliance f the city, including its officers and employees, upon the accuracy of the
information supplied to the ci apart his apps a n
SIGNATURE: DATE
PRINT NAME:
Bulletin #100 - January 29, 2016 Page 1 of 2 kAHandoutsTermit Application
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