18-104682RECEIVED
MIT APPLICATION
CITY OF Federal Way OCTVV 1 LATER + 33325 Su Avenue South + Federal Way, WA 98003-6325
Cm, }i, 5i 260A7Y FAX 253-835-2609 + permitcenter(&citvoffederalway.com
OF COMMUNITY DEVELOPMENT
PERwT NUMBER
— TARGET DATE
A-
Bulletin #100 - January 29, 2016 Page 1 of 2 k:\Handouts\Permit Application
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PROJECT VALUATION
$ pais
ZONING
ASSESSOR'S TAR/PARCEL N
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TYPE OF PERMIT
❑ BUILDING ❑ PLUMBING ❑ MECHANICAL ❑ DEMOLITION ❑ ENGINEERING 4 FIRE PREVENTION
NAME OF PROJECT
PAC; /' `L Til L. .
PROJECT DESCRIPTION
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Detailed descn]ption of work to
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be included on this permit only
NAME
PPJ39ARY PRONE
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PROPERTY OWNER
MAILING ADDRESS
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CITY
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STATE I
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ZIP
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NAME
PRONE
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MAILING ADD
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CONTRACTOR
CITY
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STATE ZIP
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FAX
WA STATE CONTRACTOR'S LICENSE Z EXPIRATION DATE
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FEDERAL WAY EUSEUM LICENSE i
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NAME
Fres
PRIMARY PHONE
MAXIMO ADD RE88
E-MAIL
APPLICANT
CITY
STATE I
W
ZIP
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FA%
PROJECT CONTACT
NAME
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PRIMARY PHONE
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MAILING ADDRESS
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E-MAIL
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(The individual to receive and
respond to all correspondence;7ce-
CITY
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STATE
WA
I ZIP
FAX
concerning this application)
PROJECT FINANCING
NAME
❑ OWNER -FINANCED
When value is $5,000 or more
(RCW 19.27.095)
MAXIMO ADDRESS, CITY, STATE, Zip -F-
PHONE
I certify under penalty of perjury that I am the property owner or authorised agent of the property owner. Z cert{fy that to the best
of my knowledge, the information submitted in support of this permit application is true and correct. I cerdfy that I will comply with
all applicable City of Federal Way regulations pertaining to the work authorised by the issuance of a permit. Z 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 a part of this application.
SIGNATURE:,DATE 10- 3
AME
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Bulletin #100 - January 29, 2016 Page 1 of 2 k:\Handouts\Permit Application
,Gt.N'1