19-10087201'.k
CITY OF
Federal Way
-/,)t/6 76 12-..
RECEIVED PERMIT APPLICATION
PERMIT CENTER + 33325 811,Avenue South + Federal Way, WA 98003-6325
FEB 2 5 2019
253-835-2607 + FAX 253-835-2609 + perinitcenter@icityoffederalway.com
ityoffederalway.com
CITY OF FEDERAL WAY
COMMUNITY DEVELOPMENT-
PERMIT NUMBER / / _ I Lo %% &— 7A— _ TARGET DATE
SITE ADDRESS
9 tA)
SUITE/UNIT k
310(5-3101-4
PROJECT VALUATIONZONING
ASSESSOR'S TAX/PARCEL d
TYPE OF PERMIT
❑ BUILDING ❑ PLUMBING ❑ MECHANICAL ❑ DEMOLITION ❑ ENGINEERING DIRE PREVENTION
NAME OF PROJECT
I V V 0 K VIA I
kf'-wL�a
PROJECT DESCRIPTION
Detailed description of work to
be included on this permit only
'
NAME
PRIMARY PHONE
wor LAC Vi I
-.._PROPERTY OWNER - ____ _.
_-MAIL G ADDRESsE-MAIL
CITY
C:) P, /00 L/ j Ae-
STATE jZ19Q040
NAME / Y�.� Y\ ♦ `. ` • V \\ \vim..
PHONE
t 56 oofo
MAILING
__ ,, �-`VV \�V�R` OV.G
LJ .
CONTRACTOR
CITYSTATE
ZIP
FAX/ ,� Q
3gq9V
FEDERAL WAY BUSINESS LICENSE R
PRIMARY PHONE
WA_ST/�� NTRACT�LICENSE ERPIRATION DATE A
NAME
MAILING ADDRESS
E-MAIL
APPLICANT-
CITY
STATE
ZIP
FAX
NAME �� {
PRIMARY PHONE
f3�10(0
PROJECT CONTACT
�!fOO
MAILING ADDR Sl c�
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E-MAIL
Ye
(The individual to receive and
respond to all correspondence
CITY
�vw.ry a.��e.�-.
STATE
v-�P•
ZIP
S\2
FAX
310 't86 81'2`t
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)
1 certify under penalty of per 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.
q
SIGNATURE: DATE ` '7 ZZ/ Z�cD 1
PRINT NAME:
Bulletin #100 — January 29, 2016 Page 1 of 2 k:\Handouts\Permit Application