18-106013RECEIVED
1%PERMIT APPLICATION
CITY OF �/ DEC 21 201
PERMIT CENTER + 33325 8th Avenue South +Federal Way, WA 98003-6325
Federal Way CITY OF FEDERAL WAY 253-835-2607 + FAX 253-835-2609 + permitcenter@cityoffederalway.com
COMMUNITY DEVELOPMENT
PERMIT NUMBER I g _ I O 1 % Q 0 ' _ P ? TARGET DATE y -
SITE ADDRESS
',Ozo S1 3Z 5-7-
SUITE/UNIT #
PRROO^JECT VALUATION �>
ZONING
ASSESSOWS TAX/PARCEL #
$ ', 1 0� p Jr
v 1 '` ( V
TYPE OF PERMIT
❑ BUILDING ❑ PLUMBING ❑ MECHANICAL ❑ DEMOLITION ❑ ENGINEERING ❑ FIRE PREVENTION
NAME OF PROJECT
C C5417 -G= jR F(_ f4 Z /9- 124,
PROJECT DESCRIPTION
Detailed description of work to
be included on this permit only
NAME
C (— CC T� 4 Z� G G
PRIMARY PHONE
PROPERTY OWNER
MAILING ADDRESS
E-MAIL
CITYj�
5 cam, / / / c :� _ ----[
STATE
ZIP
NAME � U C T/ � � � /
�V l'
PHONE
MAILING ADDRESS
Agou
E-MAIL
CONTRACTOR
CITY
STATE
ZIP
FAX
WA STATE CONTRACTOR'S LICENSE #
EXPIRATION DATE
FEDERAL WAY BUSINESS LICENSE #
NAME ,�
PRIMARY PHONE
MAII G ADDRESS
Z v TL7
E-MAIL
F1 C- L%zlnC�:2
APPLICANT-
ut3vR�/
,
CITAT
/-lid-
ZIP
O UZ
FAX
5
PROJECT CONTACT!C
NAME
&4L <= 2
PRIMARY PHONE a
ZS' ' L O
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
MAILING ADDRESS, CITY, STATE, ZIP
PHONE
(RCW 19.27.095)
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 a part of this application.
(
SIGNATURE: DATE Z? --7 j
PRINT NAME:
Bulletin #100 — January 29, 2016 Page 1 of 2 k:\Handouts\Permit Application
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