19-10086441k
CITY OF
Federal Way
RECEIVED
FEB 2 5 2019
P1_ -i
PERMIT APPLICATION
PERMIT CENTER + 33325 8th Avenue South + Federal Way, WA 98003-6325
CITY OF FEDEf�AL WAY 253-835-2601 + FAX 253-835-2609 + permitcenterc)cityoffederalway.com
COMMUNfTY DEVELOPMENT
PERMIT NUMBER / I _ I _<Q 0 O Y _ � TARGET DATE
SITE ADDRESS
S
SUITE/UNIT #
13 10 01 — -3
PROJECT VALUATION
ZONING
ASSESSOR'S TAR/PARCEL #
TYPE OF PERMIT
❑ BUILDING ❑ PLUMBING ❑ MECHANICAL ❑ DEMOLITION ❑ ENGINEERING FIRE PREVENTION
NAME OF PROJECT
V V o v I
PROJECT DESCRIPTION
Detailed description of work to
be included on this permit only
,
NAME
PRIMARY PHONE
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PROPERTY OWNER
MAILI11G ADDRESS / !
E-MAIL
CITY8, A. vjA e-
STATE I
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r �f("y
NAME ♦ ` ` v \\ v .
PHONE
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MAILING ADD -SES `
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E-MAILE�`!IL
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CONTRACTOR
CITYSTATE
,Al
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ZIP
FAX
3PU,
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C NTTRRACTOR'S LICENSE # EXPIRATION DATE
FEDERAL WAY BUSINESS LICENSEE #
WANE
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NAMEon �L
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PRIMARY PHONE
MAILING ADDRESS
E-MAIL
APPLICANT
CITY
STATE
ZIP
FAX
NAME- V V ` {
PRIMARY PHONE C,�
S�o��0
PROJECT CONTACT
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MAILING ADD S
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E -MAIL Ck Awc
(The individual to receive and
respond to all correspondence
CITY
.�ve%_� 00e_._.
STATE
"J- 4b
ZIP
FAX
300 —t$6 8Z�tZ
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 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:
JB.Iletin #100 — January 29, 2016 Page 1 of 2 k:\Handouts\Permit Application
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