15-101358CITY OF A 0 PERM ITOAPPLI CATION
Federal Way R8MM
5 _
PERMIT NUMBER i 0 2� S g' �'P MAR 19 2015
l � J
— TARGET DATE 1 WAY
SITE ADDRESS
'30/ h s W 200+� P2_ Fed-e,,ro I tV(,A
SUITE/UNIT #
�OJECT VALUATION
ZONING Z
ASSESSO�TAX/PARC # � (0 _^ –
TYPE OF PERMIT
❑ BUILDING ❑ PLUMBING ❑ MECHANICAL ❑ DEMOLITION ❑ ENGINEERING *FIRE PREVENTION
NAME OF PROJECT
eCA r� 0
PROJECT DESCRIPTION
Detailed description of work tof
1 Q. t s ✓fit �i
be included on this permit only
PROPERTY OWNER
N
PRIMARY PHONE
.S ffc) 003
MAILING KDDRESS
3 a / b St-') u +L- Pl-
E-MAIL
OLi r T1 C'rs 0w"
CITY
F LJ -f ILA 1 (/� Ju
STATE
h
ZIP
od
NAME
PHONE
MAILING ADDRESS
E-MAIL
CONTRACTOR
CITY
STATE
ZIP
FAX
WA STATE CONTRACTOR'S LICENSE #
EXPIRATION DATE
FEDERAL WAY BUSINESS LICENSE #
NAME
PRIMARY PHONE
MAILING ADDRESS
E-MAIL
APPLICANT
CITY
STATE
ZIP
FAX
PROJECT CONTACT
NAME
5t' LJ
PRIMARY PHONE
MAILING ADDRESS
EMAIL
(The individual to receive and
respond to all correspondence
CITY
STATE
ZIP
FAX
concerning this application)
PROJECT FINANCING
NAME
OWNER -FINANCED
Required value of $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. 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 ut of the reliance of the city, including its officers and employees, upon the accuracy of the
information supplied to the city a part of thi application. 2 /
SIGNATURE: DATE J 1 �qLo I
PRINT NAME: L
Bulletin 4 100 —January 1, 2013 Page I of 3 k:\Handouts\Permit Application