13-1001784%,
RECEIVE?PERMIT
VI/ay
CO2 UNIT26 7I•ELOPM FAX253-8352)AN " 201)kPPLICATION
OF FEDERAL WAY
CDS
f3-46-�2-LIX
SF MF CO ME PL DE EN FP
SITE ADDRESS
SUITE/UNIT #
3 I i.) % P�l��y�,�✓Py Svt,. tl�
*Mr(71
PROJECT VALUATION
ZONING
ASSESSOR'S TAX/PARCEL #
$ 3 7e,
vo 0 -me-
0$ 2 1 G 1-t 1
TYPE OF PERAUT
❑ BUILDING ❑ PLUMBING ❑ MECHANICAL
❑ DEMOLITION ❑ ENGINEERING FIRE PREVENTION
NAME OF PROJECT
(Tenant Name/Homeowner Last Name)
/ / p
FDG I �C� f ti V L (! I O✓� �Pi✓I t ��- /�Q �� —
22�.a�
PROJECT DESCRIPTION
(� C� t f /�Q r / f eT /Of) �✓�
Detailed description of work to
be included on this permit only
PROPERTY OWNER
NAME
pall'LI'oln CC,•t%
PRIMARY PHONE
q2 -S -L4#1-
MAILING ADDRESS
3 )2_17 Pkc,'�I c Ny j S
E-MAIL
r.•,eZ t6� �k:•.,ro
CITY
F°e jf ,-a L 1✓aIl
STATE
w4
ZIP
98,V3
Y•(y�
NAME
PHONE
MAILING ADD SS
11046
jF-MAIL
JOkn
CONTRACTOR
CITY
Tkcvwx
STATE
ZIP
94Y•24
FAX
z53 1ze< Z 3S0
WA STATE CONTRACTOR'S LICENSE #
S0=76,FS 1366 T
EXPIRATION DATE
/a X13
FEDERAL WAY BUSINESS LICENSE #
1g' 87- Oa"SS-T-M-
NAME
. � 45 lv✓I �xc�G �
PHONE
APPLICANT
MAILING ADDRESS
E-MAIL
CITY
STATE
ZIP
FAX
PROJECT CONTACT
NAME
Joh n ked e n0o r-
PHONE a
a53 2 -Ye /
(The individual to receive and
MAILING ADDRESS
1106 S�f� Ave- E
Ft -MAIL
JOI�Tr�t/
respond to all correspondence
concerning this application)
CITY �C L
/ ) ✓t lO'er
STATE
ZIP
Ll Z 1
p�/fv►-+J.f2h�[;'��,Co��1
FAX
7_S y- 2,6'- Cr7X&
ALTERNATE CONTACT NAME:
Nil'(K: UCr►�C/-
PHONE
253'Z�8'2665�
v�-wt/�S�"i�4�re�.(o
PROJECT FINANCING
NAME n
� OWNER -FINANCED
Required value of $5,000 or more
+ L
MAILING ADDRESS, CITY, STATE, ZIP
PHONE
(RCW 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.
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 a part of this application.
SIGNATURE: DATE
PRINT NAME: ) C( I^ IZ&h tr -6P'rd
Bulletin #100 —January 1, 2011 Page 1 of 3 k:AHandouts\Permit Application