16-102858_1111; ._
CITY OF
Federal Way
PERMIT NUMBER 1 V/ _
IPCEIVED
JUN 17 ZO+
CITY OF FEDERAL WAY
CDS
58
FFR
PERMIT AP ICATION
PERMIT CENTER + 33325 81h Avenue South + Federal Way, WA 98003-6325
253-835-2607 + FAX 253-835-2609 + permitcenter("r,cih•offederal«aa com
TARGET DATE Pr
SITE ADDRESS 11-7 I
SUITE/UNIT #
PROJECT VALUATION
ZONING
ASSESSOR'S TAX/PARCEL #
�� ��I �V
? 4 - 0 7
TYPE OF PERMIT
❑ BUILDING El PLUMBING ❑ MECIIANICAL El DEMOLITION ❑ ENGINEERING FIRE PREVENTION
NAME OF PROJECT
1A I rr0 •r t - A K (. V t k d '(, 1 r1 I N
in S 17� 17 tCn 6 P n 6 ie/ r,.l K (r j' f tc Al
PROJECT DESCRIPTION
Detailed description of work to
be included on this permit only
NAME ,I I
/��, I (; L L
PRIMARY PHONE
PROPERTY OWNER
MAILING ADDRESS
E-MAIL
CITY
STATE
ZIP
NAME ) �� -i
{ Gl/wn�.�i l-�1�� (�•`G Ty- L'1 fi(0'
PHONE 7
CONTRACTOR
MAILING ADDRESS
7
p
Gi �ih l'� G�Ct V[+ural. rI j
IC
CITY V • 1� 0111 V,. ` `�.
Tw-If
ZIP 1 , ` / �
5�/
FAX lr._ ' –) 6-77
WA ST TE CONTRACTOR'S LICE E M
�rj'I4<<Gi
EXPIRATION DATE
FEDERAL WAY BUSINESS LICENSE #
7- FL
NAME
PRIMARY PHONE
APPLICANT
MAILING ADDRESS
E-MAIL
CITY
STATE
ZIP
FAX
PROJECT CONTACT
NAME
�% l l /"l (i Z ri
PRIMARY PHONE
10 S j - 56�7K 115
(The individual to receive and
respond to all correspondence
MAILING ADDRESS
E��j/l t1�V kipc
concerning this application)
CITY
STATE
ZIP
FAX
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 I
correct. 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 including
person, the undersigned, and filed against the city,
but only where such cFaim arises out of the reliance of the city, including its officers and employees, upon the accuracy of the
information supplie the cit
art of this application.
SIGNATURE:
DAT E
PRINT NAME: — 1-6 A
Bulletin #100 — January 29, 2016 Page 1 of 2 k:AHandouts\Permit Application
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