19-100876A�
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CITY OF
Federal Way
PERMIT NUMBER —/
REQ; =1 V=D PERMIT APPLICATION
PERMIT CENTER + 33325 81h Avenue South + Federal Way, WA 98003-6325
FEB 2 5 2019 253-835-2607 + FAX 253-835-2609 + perinitcenter n ityoffederalway,com
° CfTY OF FEDERAL WAY
M F- r TARGET DATE
SITE ADDRESS
SUITE/UNIT #
PROJECT VALUATION
ZONING
ASSESSOR'S TAR/PARCEL #
TYPE OF PERMIT
❑ BUILDING ❑ PLUMBING ❑ MECHANICAL ❑ DEMOLITION ❑ ENGINEERING (IRE PREVENTION
NAME OF PROJECT
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PROJECT DESCRIPTION
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Detailed description of work to
be included on this permit only
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NAME
PRIMARY PHONE
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E-MAIL
PROPERTY OWNER -
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CONTRACTOR
CITY
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STATE
ZIP
FAX
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WA_3T/►� CONTRACTOR'S �LICENSE � EXPIRATION{''DATE
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FEDERAL WAY BUSINESS LICENSE #
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PRIMARY PHONE
MAILING ADDRESS
E-MAIL
APPLICANT-
CITY
STATE
ZIP
FAX
NAMEPRIMARY - {
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PROJECT CONTACT
MAILING ADDR S �(�,.� t c�
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(The individual to receive and
respond'to all correspondence
CITY
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STATE
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ZIP
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FAX
:Soo -(SCO8 i'"L'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 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 a part of this application.
SIGNATURE: DATE
` __
PRINT NAME:
Bulletin #100 - January 29, 2016 Page 1 of 2 k:\Handouts\Permit Application
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Bulletin
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