10-103857f*
L-,, .; iki:::iS. -:::Y.
Federal Way
C(WKWITY DEVELOPMENT SERVICES
2.53-835-2607• FAX 2.53-835-2609
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PERMIT
APPLICATION
-4 -�2 -'3MF CO ME PL DE EN 0
r-/`
4), ��l
SITE ADDRESS _ 4 *tel , C � � /,.^�� GL l.�
/UNIT #
PROJECT VALUATION
ZONING
ASSESSOR'S TAX/PARCEL #
TYPE OF PERMIT
❑ BUILDING ❑ PLUMBING ❑ MECHANICAL
❑ DEMOLITION ❑ ENGINEERING IRE PREVENTION
NAME OF PROJECT
(Tenant Name/ Homeowner Last Name)
�JJ `CiY
PROJECT DESCRIPTION
Detailed description of work to
` .. - 2 - v,
be included on this permit only
PROPERTY OWNER
NAME
�'7j (� �) {' L "� /7j 2' `�� l tiC k
PRIMARY PHONE
4(45-.
MAILING ADDRESS
(� L t
E-MAIL
-CITY
L.4 K. terob
STATE
ZIP
NAME
t°c'/L*4tl)(s, �!b C pdL: tee•ile�l �c
PHONE
1>3•-.S" j_7 `i
MAILING ADDRESS
Y 1 7 <• �_ �..f i v
7
E-MAIL
CONTRACTOR
CITY -
t4l i et.4h 4 %�1
STATE
ZIP
elez/6' 1
FAX
253--_S"k-�-- r& -3 -, /
WA STATE CONTRACTOR'S LICENSE /S
, EXPIRATION DATE
FEDERAL WAY BUSINESS LICENSE #
NAME ci 76 " A °
jC�ta C- � �. c c,
PHONE
26-3 - - (-�--<�-37 5
MAILING ADDRESS
'5-w,
E-MAIL
APPLICANT
CITY
t�ll(L/Ci'e"(� l i'G,Ct
STATE
G: s1
ZIP
�i�S�/�`l
FAX
;� "5 3. 54-4-'��`t t
PROJECT CONTACT
(Th e individual to receive and
NAME I
—
C e! _ C'"t ' f LCy'rx G
PHONE
-,,2!5 -•- —)rj - 7 Z- 7
MAILING ADDRESS 4.-,,
r% f ti C / '1- Ci b 0- L
E-MAIL
respond to all correspondence
concerning this application)
CITY
STATE
ZIP
FAX
-
ALCONTACTNAME:
1CS6b14,
PHONE
3 -6-32-5-
MCl'tlh/a_ 4/hL-n a )6r<
PROJECT FINANCING
NAME
OWNER -FINANCED
Required value of $5, 000 or more
MAILING ADDREsd, CITY, STATE, ZIP
PHONE
(RCW 19.27095)
I cert(& 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 to the city as apart of this application.
e
SIGNATURE: L ` DATE
PRINT NAME: � L� I 0t, L -r1 evi
Bulletin #100 - April 14, 2010 Page 1 of 3 k:\Handouts\Permit Application