13-103383CITY OF
PERMIAAPPLICATION
Federal Way RECEIVED
<� g' F JUL 31 2013 0)"'
PERMIT NUMBER
TARGET DATE CrrY QF=FFr1GAA1 IA,W
SITE
SUITE/UNIT !
/ADDRESS c Q, /
-S 0 � ✓ 0 %4�-
PROJECT VALUATION
ZONING
ASSESSOR'STAR/PARCEL t
` 1
TYPE OF PERMIT
❑ BUILDING ❑ PLUMBING ❑ MECHANICAL ❑ DEMOLITION ❑ ENGINEERING FIRE PREVENTION
NAME OF PROJECT
A04 44,15,0" 1�
(N;; LU— Nom/ w PA (3-D F14C S('9(tJiC-L Z -
PROJECT DESCRIPTION
SY,,-rc M c
fO� N£ l v l
Detailed description of work to
be included on this permit only
NAME
PRIMARY PHONE
PROPERTY OWNER
NAMING ADDRESS
E-MAIL
CITY
STATE
ZIP
S�U12tT`( f(t2E PF��C£���1
C�(,o�B�"7-10
BEAMING ADDRESS
E-KAM
CONTRACTOR
O
CITY
S�u7` ��i�t�
STATE
wa-
ZIP
�Ia3gS
FAX
WA STATE CONTRACTOR'S LICENSE Y
EXPIRATION DATE
FEDERAL WAY BUSINESS LICENSE !
u Doo 6r
17-/ 31 / 13
tut 3-roo4,54
NSAME E galTy F'1 IQE P-6T� 1-->r l
PRIMARY3( .D)bgN - 683 `t
APPLICANT
MnADDRESS
U t�oX 4- a"7
E-MAIL
TO c;T"E, � tt2lE
WESTATE
ZIP
q$3 SS
FAX
N
JA Ia—ft—L Az;�, ox&YL.
PRIMARY PHONE
(204o)'T53 -4 b+3 -00 �L
PROJECT CONTACT
MAIyING ADDRESS
M 0--e-
E -MA IL
(The individual to receive and
respond to all correspondence
CITY
STATE
ZIP
FAX
concerning this application)
concerning
PROJECT FINANCING
NAME
❑ OWNER -FINANCED
Required value of $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 authorised 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 authorised 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 o ederal Way as to any claim (including costs, expenses, and attorneys' fees incurred in
the investigation an f f such ciai , w ch maybe made by any person, including the undersigned, and filed against the city,
but only where sue cl se oto the reliance of the city, including its officers and employees, upon the accuracy of the
information suppli to ci a of is application.
SIGNA DATE
PRINT NAME:
Bulletin #100 - January 1, 2013 Page 1 of 3 k:\Handouts\Permit Application