13-104042RECEIVED
CITY OF 4AS61 SEA2 2013 PERM I14PAPPLI CATION
Federal Way
CITY OF FEDERAL WAY
CDS
PERMIT NUMBER _ /) _ TARGET DATE
SITE ADDRESS
1' b '5. Carl molts Way
SUITE/UNIT i
PROJECT VALUATION
$ _ /OZ boo -
ZONING
ASSESSOR'S TAX/PARCEL #
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TYPE OF PERMIT
UILDING ❑ PLUMBING ❑ MECHANICAL ❑ DEMOLITION ❑ ENGINEERING ❑ FIRE PREVENTION
NAME OF PROJECT
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PROJECT DESCRIPTION
Detailed description of work to
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be included on this permit only
PROPERTY OWNER
NAME Q
PRIMARY PHONE
ON� • BS�. O 100
MAILING ADDRESS
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NAME
Pis . a�4 ,4000
MAIyTitG ADDRESS /� G Q TM ('
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CONTRACTOR
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WA AT C O 'S IC S Y
EXPIRATION DATE
FEDERAL WAY BUS LICENSE 9
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NAME 1 ,O
PRIMARY PHONE `
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APPLICANT
MAIL G ADDRESS ✓C A f u • ^
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NAME
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PRUMRY PHONE
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PROJECT CONTACT
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(The individual to receive
respond to all correspondence
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FAx
concerning this application)
PROJECT FINANCING
NAME
❑ OWNER -FINANCED
Required value of $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. 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
PRINT NAME: ") 1 • w�1 •
i
Bulletin #100 — January 1, 2013 Page I of 3 k:\Handouts\Permit Application
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