19-100874REC-F--I ED
CITY OF
Federal Way FEB 2 5 2019
4,-/ayo Id-- l2 - V
PERMIT APPLICATION
PERMIT CENTER + 33325 811, Avenue South + Federal Way, WA 98003-6325
253-835-2607 + FAX 253-835-2609 + permitcenter&ityoffederalway.com
9 C TY OF FEDF ,1. PERMIT NUMBER _j_4oro LoAL# _ r D TARGET DATE
SITE ADDRESS
9% / - /�f 0 �r
SUITE/UNIT k
PROJECT VALUATION
$
ZONING
ASSESSOR'S TAR/PARCEL 9
: Jam- qa
TYPE OF PERMIT
❑ BUILDING ❑ PLUMBING ❑ MECHANICAL ❑ DEMOLITION ❑ ENGINEERING C9IRE PREVENTION
NAME OF PROJECT
+ V Y Oa Le,V
V O-" t&C
PROJECT DESCRIPTION
Detailed description of work to
be included on this permit only
NAME
PRIMARY PHONE
i ae UL
MAIL G ADDRESS -- _.-- _ __ _ _ __ --
S -MAIL
PROPERTY OWNER-
CITY
STATE
Z19 O i(i`g
i
NAME ��� �� ♦ `
PHONE
MAILING/D�ESSE-MAIL
O` ✓ J `
J ,
CONTRACTOR
CITY
v qvW
STATE
4,
ZIP
c\ 6s- k -Z
FAR
3(-0 -Z gS- i37Zz
J�c'i �go .
FEDERAL WAY BUSINESS LICENSE N
-1 OS (` /95
PRIMARY PHONE
�
WA_ST/1�CONTRACTOR'S LICENSE # 1 EXPIRATION DATE
YV1 pC�
NAME
MAILING ADDRESS
E -MAD.
APPLICANT-
CITY TiT"
P
FAX
NAME �� {
vv
PRIMARY PRPHONE
�(0o(o
PROJECT CONTACT
C�
MAILING ADDRISS
0\710' x" - "" �\ sw
E-MAIL
`'- k� V �
(The individual to receiue and
respond to all correspondence
CITY
�vw.'v 0-�
STATE
ZIP
FAX
34;D
concerning this application)
PROJECT FINANCING
NAME
❑ OWNER -FINANCED
When value is $5,000 or more
MAILING ADDRESS, CITY, STATE, ZIP
PHONE
(RCW 19.27095)
I certify under penalty of perfiLry 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 t the city as apart of this application.
SIGNATURE: DATE
PRINT NAME:
Bulletin #100 — January 29, 2016 Page 1 of 2 k:\Handouts\Permit Application
3!