19-100967CITY OF RECEIVED PERMIT APPLICATION
-
Federal Way PERMIT CENTER + 33325 W, Avenue South + Federal Way, WA 98003-6325
FEB 2 8 2019 253-835-2607 + FAX 253-835-2609 + perniitcentertacitvoffederalway.com
CITY OF FEDERAL WAY
PERMIT NUMBER
COMM Nf1Y DEVELO
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X11 TARGET DATE J �1
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SITE ADDRESS
SUITE/ON #
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PROJECT VALUATION
ZONING
ASSESSOR'S TAR/PARCEL #
TYPE OF PERMIT
❑ BUILDING PLUMBING ❑ MECHANICAL ❑ DEMOLITION ❑ ENGINEERING FIRE PREVENTION
NAME OF PROJECT
c❑
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PROJECT DESCRIPTION
Detailed description of work to
be included on this permit only
N
Y
PRUTARY PHONE
PROPERTY OWNER
MA& D a
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BTI►,T$�
ZIP iOJ
(l` �
NAME
PHONE
MAILING ADD
015Z0 Ili AV& 543tDv
E-MAIL
CONTRACTOR
CITY
St+•rr�e
STATE
WA
ZIP
618101
FAX
WA STATE CONTRACTOR'S LICENSE #
EXPIRATION DATE
FEDERAL WAY BUSINESS LICENSE #
NAME
301AY4
PRIMARY PHONE
ab• N7p1• 7.37q
MAILING wDlb"b Ave S 1�%J
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APPLICANT
CITY
tAS'rc�
STATEFAR
WIG
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FAX.) 4S. Gown
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PHONE
43 P Yi ZZ "'RA I
PROJECT CONTACT
MAILING ADDRESS
E-MAIL
CO�C�•yi
(The individual to receive and
respond to all correspondence
��� �.SQ.0 •
CITY
STATE
I ZIP
FAX
concerning this application)
PROJECT FINANCING
NAME
❑ OWNER -FINANCED
When value is $5,000 or more
MAILING ADDRESS, CITY, STATE, ZIP
PHONE
(?CW 19.27095)
I certify under penalty of perjury that I am the property owner or authorised 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 authorised 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 ojJRcers and employees, upon the accuracy of the
information supplied to the as apart of this application.
ecity
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SIGNATURE: .Y" "y�' DATE�bq
PRINT NAME: ba4!y
Bulletin #100 — January 29, 2016 Page 1 of 2 k:\Handouts\Permit Application
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