16-104619` S4.
AIVM IV -d0 A.1.I7
CITY OF
Federal Way 9101 S 1 d3S
r k
PERMIT NUMBER
PERMI14kPPLICATION
PERMIT CENTER + 33325 8th Avenue South + Federal Way, WA 98003-6325
253-835-2607 + FAX 253-835-2609 + permitcenter@cityoffederalway.com
_9 TARGET DATE
SITE ADDRESS
SUITE/UNIT #
`d3(o 3uo 31Q- h 5� -�csleral Wo-,� , WA q'3L-)Q3
PROJECT VALUATION
5O)q 0 �
ZONING
ASSESSO TAx/PARC
7 — —
TYPE OF PERMIT
❑ BUILDING ❑ PLUMBING ❑ MECHANICAL ❑ DEMOLITION ❑ ENGINEERING 'X FIRE PREVENTION
NAME OF PROJECT
PROJECT DESCRIPTION
i rn err R)
Detailed description of work to
I S Li ('1 n
adni n n e.
be included on this permit only
e—f icuQo
NAME
Q e, , LLC
PRIMARY PHONE
-4-Q • X43 5 1 a
PROPERTY OWNER
MAILING ADDRESS
E-MAIL
CITY 'KJ ^ ,t (,- v `LC
STATE
W �
ZIPp
9 l O 0 09
NAME
`;YI(°ricican u F.lec- ric
PHONE
5 •44co•4voQ
MAILING ADDRESS
I I I C)q 3
E-MAIL
CONTRACTOR
CITY^
STATE ZIP
�Xl A Q (8 -:3-13EXPIRATION
FAX
WA STATE CO CTOR'S LICENSE # DATE
FEDERAL WAY BUSINESS LICENSE #
YYl F- l CG 18 3G -
-NAME
NAME
& i•n n
PRIMARY PHONE
MAILING ADDRES
0-Lh Av(A
E-MAIL
APPLICANT
CITY p
STATE
ZIP
FAX
PROJECT CONTACT
NAME
1 `ram 1 5 B r u 550
PRIMARY PHONE
I
MAILING ADDRESS
0�0 ��+h Ave' 5
E-MAIL
(The individual to receive and
respond to all correspondence5
CITY
STATEZIP
t�A
9F108
FAX
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. 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 apart of this application.
�y
SIGNATURE. DATE
PRINT NAME:
Bulletin #100 — January 29, 2016 Page 1 of 2 k:\Handouts\Permit Application