13-100570CITY OF ` IDECEIVED
Federal Way
FEE 0 5 2013
PERM IVAPPLICATION
PERMIT NUMBER / _ /�) -%o
TARGET DATE
SITE ADDRESS
SUITE/UNIT #
PROJECT VALUATION
ZONING
ASSESSOR'S TAR/PARCEL #
TYPE OF PERMIT
❑ BUILDING ❑ PLUMBING ❑ MECHANICAL ❑ DEMOLITION ❑ ENGINEERING iI FIRE PREVENTION
NAME OF PROJECT
C � �� R-� 1 DLt-klc
PROJECT DESCRIPTION
3
Detailed description of work to
be included on this permit only
NAME
PRIMARY PHONE
PROPERTY OWNER
MAILING ADDRESS
E-MAIL
CITY
STATE
ZIP
NAME
cvr�(Ty F1reE j'p -rr1=cTl--r1
PHONE
MAILING ADDRESS
` x 4-'%-7
E-MAIL
CONTRACTOR
CITY�p
��UH I ��i21<✓
�t4
`�>�
FAX
Lin
WA STATE CONTRACTOR'S LICENSE #
cxz =' p�
EXPIRATION DATE
FEDERAL WAY BUSINESS LICENSE #
NAME
MIcA-4A&-
PRIMARY PHONE
(2,Y'q5-3
MAILING ADDRESS
E-MAIL
APPLICANT
CITY
STATE
ZIP
FAX
PROJECT CONTACT
NAME
a i I & u A-, V-
PRIMARY PHONE
C'-2 .)`153
MAILING ADDRESS
F -MAIL
(The individual to receive and
respond to all correspondence
CITY
STATE
ZIP
FAX
concerning this application)
PROJECT FINANCING
NAME
❑ OWNER -FINANCED
Required value of $5,000 or more
(RCW 19.27.095)
MAILING ADDRESS, CITY, STATE, ZIP
PHONE
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 Iocal, 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 defer;se of such claim), w Bch may be made by any person, including the undersigned, and filed against the city,
but only where such c ,arises, out of'the reliance of the city, including its officers and employees, upon the accuracy of the
information supplied t city a art oft is (zpplication.
SIGNATU DATE
PRINT NAME:
Bulletin #100 -January 1, 2013 Page 1 of 3 k:AHandouts\Permit Application