11-101033AN, -
CITY OF
Federal Way
COMMUNITY DEVELOPMENT SERVICES
253-835-2607• FAX 253-835-2609
UIJ'(ttl-am"
9PERMIT
APPLICATION
CUE03? 3
SOMF CO ME PL DE ENO
RECEIVED
MAR 1 8 )^.,s
SITE ADDRESS SUITE/UNIT #
2 i;� 5 { s C v OD `' ,0� CITY OF FEDERAL WAY
PROJECT VALUATION
$ -j
ZONING
�;
ASSESSOR'S TAX/PARCEL #
TYPE OF PERMIT
❑ BUILDING ❑ PLUMBING ❑ MECHANICAL
❑ DEMOLITION ❑ ENGINEERING Q FIRE PREVENTION
NAME OF PROJECT
(Tenant Name/Homeowner Last Name)
PROJECT DESCRIPTION
Detailed description of work to
ltiL ''G
�� Q
be included on this permit only
NAME
PRIMARY PHONE
PROPERTY OWNER
MAILING ADDRESS
E-MAIL
CITY
STATE
ZIP
NAME !`J -� --,---
PHONE
MAILING AEhiRESS �/,
"_'7 "r �4L C G r ` L_
cll 41- ,1/t
EMAIL
/bl- C! CIwU
CONTRACTOR
CITY ; qk "'CA -41 �.
b4iV `'tet C
STATE
tO l.1
ZIP
g6 -y b-1
FAX , i2.(
Al 3 -Sib-T6i (
WA STATE CONTRACTOR'S LICENSE #
EXPIRATION DATE
FEDERAL WAY BUSINESS LICENSE #
NAME._
lC6t
PHONE
_cE - 3z
MAILING ADDRESS
E-MAIL
APPLICANT
CITY
STATE
ZIP
FAX
PROJECT CONTACT
(The individual to receive and
NAME �
v t GLc�D
PHONE
X53
MAILING 40DRESS C/, / n
4t° a -;f-
"concerning
E-MAIL
respond to all correspondence
this application)
CITY
STATE
ZIP
FAX
ALTERNATE CONTACT NAME:
PHONE
E-MAIL
PROJECT FINANCING
NAME
OWNER -FINANCED
Required value of $5,000 or more
MAILING ADDRESS, CITY, STATE, ZIP
PHONE
tRCW 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.
]'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 a part of this application.
SIGNATURE: Yl DATE
PRINT NAME: ! ` y v G O/;? 0
Bulletin #100— January 1, 2011 Page] of 3 kaHandoutsTermit Application