19-100924` RECEIVED
CITY OF PERMIT APPLICATION
FEB 2 6 2019 PERMIT CENTER + 33325 8w Avenue South + Federal Way, WA 98003-6325
Federal Way CITY OF FEDERAL WAY 253-835-2607 + FAX 253-835-2609 + permitcenterr@icityoffederalway.com
COMMUNITY DEVELOPMENT
PERMIT NUMBER _ / � _ /��
�1 L TARGET DATE
SITE ADDRESS ` , A
2 c g L$ �GL t T �� C l� ' !� w vy� sov/ A F� lk l G/Gt� W
SUITE/UNIT #
PROJECT VALUATION
ZONING
ASSESSOR'S TAX/PARCEL #
TYPE OF PERMIT
❑ BUILDING ❑ PLUMBING ❑ MECHANICAL I]DEMOLITION I]4/J ENGINEERING FIRE PREVENTION
NAME OF PROJECT
R Q P` o C e i bQ Q 1 )) a I VNx f
PROJECT DESCRIPTION
Detailed description of work to
be included on this permit only
NAME
Y `�e L icr,
PRIMARY PHONE
(z06) q 3/-200 2
PROPERTY OWNER
MAILING ADDRESSE-MAIL
�QCj i
2
CITY
STATE
A
wNAME
ZIP
dD
I
9R6LS LiC /�4Nu `jc a
42S 3D6-9/Sd
MAILING ADDRESSE-MAIL
21 St g0 G q t k �
QY1q p tS � 1 1oe5 'N e
j
CONTRACTOR
CITY
S ek -yr W G VVI i s 11
STATE
ZIP
o 4
FAX
WA STATE CONTRACTOR'S LICENSE #
!rS
EXPIRATION DATE
FEDERAL WAY BUSINESS LICENSE #
�S L 2B
if0 120
N 14
_
NAME eC Qa, C c,
7
PRIMARY PHONE ��D
C4_z 36tf`
APPLICANT-
_
Z l S 5D A) L {
6 .) d
a r h am^ f 1
CITY
SOL rn
STATE
IUIA
ZIP
CIS&.#
FAX
PROJECT CONTACT
NAME JI
� r e W C a
PRIMARY PHONE
(20,e) 93/ — Z 610 2
MAI,ZLING Cl � � $ ADDRE6S a fit. � H� � S r
PE-MMI,
(The individual to receive
respond to all correspondence
CITYSTATE
F 4 '. E:�:�. d
l v A
q d o J
FAX
concerning this application)
PROJECT FINANCING
NAME I
Er OWNER -FINANCED
When value is $5,000 or more
MAILING ADDRESS, CITY, STATE, ZIP
PHONE
(RCW 19.27095)
I certify under penalty of perft" that I am the property owner or authorized agent of the property owner. 1 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 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.
Z /% e c
SIGNATURE: DATE /
PRINT NAME: Yl C - M 8 0 C
Bulletin #100 - January 29, 2016 Page 1 of 2 k:\Ilandouts\Permit Application