19-1003957
41kRECEIVEDPERMIT APPLICATION
CITY OF►�...-JAN 2 3 2019
PERMIT CENTER + 33325 8th Avenue South +Federal Way, WA 98003-6325
Federal Way 253-835-2607 + FAX 253-835-2609 + permitcente ctcityoffederalway.com
CITY OF FEDERAL WAY
COMMUNt1YD��]EVELOPMEN,,,..TI, ,/�
PERMIT NUMBER / 9 — ///
D 0 a � 5— _ (r 7� -
L / TARGET DATE
SITE ADDRESS
SUITE/UNIT #
2.1 124" � oz3
PROJECT VALUATION
ZONING
ASSESSOR'S TAX/PARCEL #
TYPE OF PERMIT
❑ BUILDING ❑ PLUMBING ❑ MECHANICAL DEMOLITION ❑ ENGINEERING L7h[RE PREVENTION
NAME OF PROJECT
C❑
PROJECT DESCRIPTION
Detailed description of work to
be included on this permit only
PROPERTY OWNER
NAME
PRIMARY PHONE
MAILING ADDRESS
E-MAIL
CITY
STATE
ZIP
NAME
Q—, �as2a•:�7—SD��
PHONE
MAILING ADDRESS
'
E-MAIL `
CONTRACTOR
�CITY`
STATE
uj
7?S � �
FAX
WA STATE CONTRACTOR'S LICENSE #
EXPIRATION DATE
/ i / Z.V
FEDERAL WAY BUSINESS LICENSE #
NAME -�
PRIMARY PHONE
--')
X ,5 54964Cs
APPLICANT
MAILING ADDRESS p
E-MAIL �^
CITY
STATE
ZIP
i V
FAX
PROJECT CONTACT
NAME
v, ,2.
PRIMARY PHONE c'
&-,s 7
MAILING ADDRES.. S G
ij(-> �,
E rL
`
(The individual to receive and
respond to all correspondence
CITY
STATE2IP
FAX
concerning this application)
PROJECT FINANCING
NAME
El—OWNER-FINANCED
When value is $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. 1 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.
SIGNATURE: < DATE 1/"I
PRINT NAME:A'�k-
Bulletin 4100 — January 29, 2016 . Page I of 2 k:AHandouts\Pennit Application