10-103951Federal Way
CONWI,NITV DEI'ELOPMENT SERVICES
2.53-835-2607• FAX 253-835.2609
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HERMIT
APPLICATION
S F CO ME PL DE E FP
RECEIVED
SEP 16 2010
SITE ADDRESSCrI'-r
� � � CI
33 U� � PA-U 1'-t G w 1CDS
•Ci7LTi'F11_. WAY
PROJECT VALUATION
$ a,G OCA
ZONING
ASSESSOR'S TAX/PARCEL #
./ Z .2- o
TYPE OF PERMIT
❑ BUILDING ❑ PLUMBING ❑ MECHANICAL
❑ DEMOLITION ❑ ENGINEERING ❑ FIRE PREVENTION
NAME OF PROJECT
(Tert(int Narrte/Homeowner Last Name)
ce_t_ l�
PROJECT DESCRIPTION
Detailed description of work to
LoMr►1E2c(.,O� JI 2E SU ppAFSs t oIJ 11,J P0 --t &jT"
M l X P.p o M
be included on this permit only
PS:_-_tJ . F LF SU P Q A/11'W U �� r- gYj,_/�7,1 l
PROPERTY OWNER
NAME
PRIMARY PHONE
MAILING ADDRESS
E-MAIL
CITY
STATE
ZIP
NAME �-�SS Mr Ft vIV
PHONE
MAILING ADDRESS
�6/� 7573
E-MAIL
CONTRACTOR
CITY
STATE
�A
ZIP
���y�
FAX
YiL/9
WA STATE CONTRACTOR'S LICENSE #
R�crasr 9 tTF
EXPIRATION DATE
i i
FEDERAL WAY BUSINESS LICENSE #
NAME
PHONE_3 _O
APPLICANT
MAILINADDRESS
�� x ?s?3
E-MAIL
`
CITY
cam,, LAG ;ati,
STATE
c� r�
Z
� 2-
FAX
V(3
PROJECT CONTACT
(The individual to receive and
NAME
�n �r c� G 1�1 L U
PHONE
L
/ 2S q� 3 �° 7 "
MAILING DRESS �j
b o X 7.,5- (3
E-MAIL
respond to all correspondence
concerning this application)
CITY V t &j G -16/,)
` ,� r,
STATE
IP
,Y t`�/
ZIP ! (� 6 !�
FAX —/ 5��� 2 -
ALTERNATE CONTACT NAME:
CHAD C Ct£� No FT -7
PHONE
7oZ`/-3.222
E-MAIL
PROJECT FINANCING
Required value of $5, 000 or more
NAME
OWNER -FINANCED
MAILING ADDRESS, CITY, STATE, ZIP
PHONE
(RCW 19.27095)
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.
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 q /1 /� C)
PRINT NAME:
Bulletin #100 — April 14, 2010 Page I of 3 k:\Handouts\Perrnit Application
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