18-105981RECEIVED PERMIT APPLICATION
CITY OF
Federal Way DEC 2 0 2018 PERMIT CENTER + 33325 81h Avenue South + Federal Way, WA 98003-6325
253-835-2607 + FAX 253-835-2609 + permitcenten(icityofl'ederalway.com
CITY OF FEDERAL WAY
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D L MENT
PERMIT NUMBER ,r N
TARGET DATE.
SITE ADDRESS
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SUITE/UNIT #
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PROJECT VALUATION
ZONINGESSOR'S
TAX/PARCEL #
$ \a- c) p
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TYPE OF PERMIT
❑ BUILDING ❑ PLUMBING ❑ MECHANICAL ❑ DEMOLITION ❑ ENGINEERING VFIRE PREVENTION
NAME OF PROJECT
N
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PROJECT DESCRIPTION
Detailed description of work to
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be included on this permit only
NAME
PHONE
PRIMARY4'7
PROPERTY OWNER
MAILING ADDRESS
"E-MAIL
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STATE
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ZIP
NAME
PHONE
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MAILING DRESS
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E-MAIL
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CONTRACTOR
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STATE
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ZIP
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FAX
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WA STATE CONTRACTOR'S LICENSE #
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EXPIRATION DATE
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FEDERAL WAY BUSINESS LICENSE #
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NAME
PRIMARY PHONE
MAILING ADDRESS
E-MAIL
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APPLICANT
CITY
STATE
ZIP
FAX
PROJECT CONTACT
NAME
PRIMARY PHONE
MAILING ADDRESS
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E-MAIL
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(The individual to receive and
respond to all correspondence
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CITY
STATE
ZIP
FAX
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concerning this application)
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. 1 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 the city, including its officers arzd employees, upon the accuracy of the
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information supplied to the city as pa of thign.
SIGNATURE: DATE
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PRINT NAME: ` i l LUQ17 G
Bulletin 1-t100 - January ?9, ?016 Page 1 of 2 k:AHandouts\Permit Application
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