19-100875�► PERMIT APPLICATION
CITY OF ne!
FEB 2 5 ' 2PERMIT CENTER + 33325 8Avenue South + Federal Way, WA 98003-6325
Federal Way 3811,253-835-2607 + FAX 253-835-2609 + permitcente a ityoffederalway.com
CITY OF FEDERAL WAY
�j COMMUNITY DEVELuFMEW-,
PERMIT NUMBER _j1%�Flo
V D — TARGET DATE
SITE ADDRESS
SUITE/UNIT #
g S 9- S 9 S
PROJECT VALUATION
$
ZONING
ASSESSOR'S TAR/PARCEL #
J
D
-
TYPE OF PERMIT
❑ BUILDING ❑ PLUMBING ❑ MECHANICAL ❑ DEMOLITION ❑ ENGINEERING *RE PREVENTION
NAME OF PROJECT
( V V Q V t
5
iP,
PROJECT DESCRIPTION
Detailed description of work to
be included on this permit only
,PRIMARY
NAME
PHONE
r_ LaLe Vi- Lff-
MAIL G aDDRESs --_ _ ____ __ _ _ 77
E-KAjL
PROPERTY OWNER .
CITY
STATE
Z1q 04
I
NAME •
PHONE
MAILI _G ` l% V' �� \
�1\
�CJE-MAIL�JJ l
CONTRACTOR
CITYSTATE
ZIP
FAX
3p [ g;-,
WA_STAE CONTRACTOR'S LICENSE # EXPIRATION DATE
NAME
FEDERAL WAY BUSINESS LICENSE #
PRIMARY PHONE
MAILING ADDRESS
E-MAIL
APPLICANT
CITY
STATE
ZIP
FAX
NAME
PRIMARY PHONE
bcoo(o
PROJECT CONTACT
C��1,80
MAILING ADDR St
�A�' �� �\ ` " 5W
E-
\rMAIL
Ve
(The individual to receive and
respond to all correspondence
CITY
77
STATE
v�A
ZIP
'ZISk
FAX -
:Soo -186 8`12-1-
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 1 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 the city as apart of this application.
SIGNATURE: _ DATE ZZ
Win
PRINT NAME:
Bulletin #100 — January 29, 2016 Page 1 of 2 k:\Handouts\Permit Application
M