11-103656. >
IRE,
ciroF ,ERMIT
Federal Way Sip 2 :iceP
COM " DEVELOPMENT SERVICES N AT I O N
2533835 2-835-2607• FAX 253-835-2609 � � p++�
auw.rl[y„1'ederain4j[°Dry'� ��"••CbS
SF MF CO ME PL DE E F
SITE ADDRESS
023,,!� tj RS023
SUITE/UNIT S
PROJECT
ZONING
ASSESSOR'S TAx/P CEL N
ffVA�LUATION
$ ��V o�
7 S g YI 0- Q b
TYPE OF PERMIT
❑ BUILDING ❑ PLUMBING ❑ MECHANICAL
❑ DEMOLITION ❑ ENGINEERING FIRE PREVENTION
NAME OF PROJECT
(Tenant Name/Homeowner Last Name)
C
Pt -5 fex IA4; ,` FPA 61) Pire r 1 { J 45fm
PROJECT DESCRIPTION
Detailed description of Mork to
be included on this permit only
PROPERTY OWNER
NAME
L; vA vie 6 1vi 5 De- b Y'n
PRIMARY PHONE
MAILING ADDRESS
223 5W3 13 fi, sfi
E-MAIL
CITY
Fc�erc+ 1 wn
STATE
G-9 q
ZIP
—90623
^ �
NAME L (_
to, to 9 Yl 51 A r�5 �i f � T ^ti f iec.4 S
PHONE
475 160
MAILING ADDRESSE-MAIL
�3 E Sfi # IO I
r
CYs� Ci,, QST • L(S
CO CTOR
CITY
2e
STATE
ZIP
986 s 2
FAR
4t! S&( 5650
V, en
WA STATE CONTRACTOR'S LICENSE I
EXPIRATION DATE
FEDERAL WAY BUSINESS LICENSE N
1��51E5f13(�C�F
f2 i 31 i ff
M-9 .fb tq 00
NAME
PHONE
g�w.c A5 C vl F�ActoY
MAILING ADDRESS
E-MAIL
APPLICANT
CITY
STATE
ZIP
FAX
PROJECT CONTACT
NAME
PHONE
(The individual to receive and
MAILING ADDRESS
E-MAIL
respond to all correspondence
concerning this application)
CITY
STATE
ZIP
FAX
ALTERNATE CONTACT NAME:
PHONE
425 73& 2
UMAIL
PROJECT FINANCING
NAME
r -
OWNER -FINANCED
Required value of $5,000 or more
(RCW 19.27.095)
� D
1114
MAILING ADDRESS. CITY, STATE, ZIP
\G�� PHONE
l ) 3qn-$
fo m i lc
1B6,
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.
DATE I I
SIGNATURE:
PRINT NAME: ` 0 i v.
Bulletin #100 —January 1, 2011 Page I of 3 k:AHandouts\Perrnit Application