14-103222** -4k
CITY OF
Federal Way
' *CEMM
JUL 0 2 2014
PERMIT APPLICATION
/ CITY OF FEDQE�RALL� WAY
PERMIT NUMBER J _ / 3
Ll
TARGET DATE
SITE ADDRESS -
-
SUITE/UNIT #
j
tc- l�1 �Wy .5 ,
PROJECT VALUATION
ZONING
ASSESSOR'S TAX/PARCEL #
TYPE OF PERMIT
❑ BUILDING ❑ PLUMBING ❑ MECHANICAL ❑ DEMOLITION ❑ ENGINEERING rX FIRE PREVENTION
NAME OF PROJECT
`r_ C—
PROJECT DESCRIPTION
Detailed description of work to
A -r (
be included on this permit only
PROPERTY OWNER
NAME
C-UTZ�'C T L'l(J_ZA;C -
PRIMARY PHONE ~�
MAILING
) d9 n w� -
I' l-
E MAH.
CI (2n3
. pe' -e
U, -L-
STAT $
ZIP
,c `�1�
J
NAME
PHONE
MAILING ADDRESS
% ��^' '
E-MAIL n
Fbm %Vkk 1 2F'
CONTRACTOR
CITY
Sm
ZIP
FAX
WA STATE CONTRACTOR'S� CENSE #
IRATION DATE
FEDERAL WAY BUSINESS LICENSE #
NAME ^
PRIMARY PHONE
MAILING ADDRESS �t�
E-MAIL24GMT'Ak C- J
APPLICANT
CITY STATE_
ZIP �
FAX
NAME
cv\
PRIMARY PHONE
PROJECT CONTACT
15a
MAILING ADDRESS R p
lc)
E-MAIL
(The individual to receive and
respond to all correspondence
CITY
�s>Ai&�7�
STAT
�� -
ZIP
FAX
concerning this application)
PROJECT FINANCING
NAME , "\,
0_1
OWNER -FINANCED
Q
Required value of $5,000 or more
(RCW 19.27.095)
MAILING ADDRESS, CITY, STATE, ZIP
C PHONE
•� J'� �.?'2 J r �����J
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 ses out of the reliance of the city, including its officers and employees, upon the accuracy of the
information supplied to the ci as a art of this application.
SIGNATURE: DATE
PRINT NAME:
Bulletin # 100 —January 1, 2013 Page 1 of 3 k:\Handouts\Permit Application
P
2