19-100163CITY OF
Federal Way
RECEIVEDPERMIT APPLICATION
JAN 0 9 201
F"A�l PERMIT NUMBER C `O MF p klt�
TARGET DATE
SITE ADDRESS
3`{ 1 00 IT" AVr NUS SVV i H ;�6PE 14- 1_ Wfl`(, WA 9-9003
SUITE/UNIT #
PROJECT VALUATION
ZONING
ASSESSOR'S TAX/PARCEL #
— — — — — — —
TYPE OF PERMIT
❑ BUILDING ❑ PLUMBING ❑ MECHANICAL ❑ DEMOLITION ❑ ENGINEERING X FIRE PREVENTION
NAME OF PROJECT
S f"L. N\0u"' l BLDG, — �'Z- i �Rpcln i pb
PROJECT DESCRIPTION
Detailed description of work to
d APPwF 1 (s,,NED Q Pep- WFPA 13
P1
be included on this permit only
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NAME
PRIMARY PHONE
PROPERTY OWNER
KR-_
1�3ie - '113 - 3S'{ (,
MAILING ADDRESS
X03 -wQ 3r'o-rx cT
E-MAIL
CITY
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STATE
IWA
ZIP
NAME
P.R�NE1Z CJiJS'rt2.d�-"Clot,:
PHONE
CONTRACTOR
MAILING ADDRESS
E-MAIL
CITY
K1 !AT
STATE ZIP
\I'� � �1% o 3 a -
FAX
WA STATE CONTRACTOR'S LICENSE # EXPIRATION DATE
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FEDERAL WAY BUSINESS LICENSE k
NAME
r^PTH6w 'T?AkAAV\�; _r
PRIMARY PHONE
"''3 - 8-1a - i J'17 EXT 3ar�
MAILING ADDRESS
73 51SS. SOC TR ST�EI
E-MAIL
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APPLICANT
CITY
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STATE
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ZIP
FAX
PROJECT CONTACT
NAME
I-iP� ''U�V��K� �
PRIMARY PHONE
'3- Z7a - �,;L EXT:
MAILING ADDRESS
7 Q SCJ S . 34v�i1 `�j��C r
E-MAIL
NVQ? �C� �P,?Lj1��C�N�TR4CT1
(The individual to receive and
respond to all correspondence
CITY
KE QT
STATE
tivf�
ZIP
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FAX
concerning this application)
PROJECT FINANCING
NAME 4<11�F kVi (.�IJS
OWNER -FINANCED
Required value of $5,000 or more
(RCw19.27.095)
MAILING ADDRESS, CITY, STATE, ZIP
7o3 SW '35d7H C,T,� liE'. ijZUJ�,y �'Vfi ,��0�3
PHONE
JIO - 713 - _; i,64
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 o i plication.
SIGNATURE: - -' — — DATE \' O� �` acUtz3
PRINT NAME: HAAT 7 -it
Bulletin #100 —January 1, 2013 Page I of 3 k:\Handouts\Permit Application
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