11-102096�p
PERMIT
R�l Way
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COMMUNIT V�L((��f1p17'�RVII's Y APPLICATION
253-835- pNC 253-835-2609
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SF MF CO ME PL DE EN FP
A PPS
ITE ADDRESS
SUITE/U
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PROJECT VALUATION
ZONING
ASSESSOR'S TAR/PARCEL X
2-30
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TYPE OF PERMIT
❑ BUILDING ❑ PLUMBING ❑ MECHANICAL
❑ DEMOLITION ❑ ENGINEERING 09 FIRE PREVENTION
NAME OF PROJECT
(Tenant Name/Homeowner Last Name)
PROJECT DESCRIPTION
Detailed description of work to��
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be included on this permit only
NAME
PRIMARY PHONE
PROPERTY OWNER
MAILING ADDRESS
E-MAIL
CITY
STATE
ZIP
NAME �� aM �e ;
(7o6) S 1268
MAILING ADDRESS /�., �p
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CONTRACTOR
CITY
STATE
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ZIP�. 8 r 3
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WA STATE CONTRACTOR'S LICENSE M EXPIRATION DATE
FEDERAL WAY BUSINESS LICENSE M
NAMENE
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MAD. G ADDRESS
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APPLICANT
CITY
n
SPS C.
W /Z
ZIP
PROJECT CONTACT
(The individual to receive and
NAME (�
a.,,,�
PHONE
MAILING ADDRESS t(
EMAIL t
respond to all correspondence
concerning this application)
CITY C
STATE
ZIP
FAX
ALTERNATE CONTACT NAME:
PHONE
E-MAIL
PROJECT FINANCING
NAME
❑ OWNER -FINANCED
Required value of $5,000 or more
(RCW 19.27.095)
MAILING ADDRESS, CITY, STATE, ZIP
PHONE
I certM under penalty of perjury that I am the property owner or authorized agent of the property owner. I certVy 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,
construction or environmental laws.
or federal laws regulating
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 th8 accuracy of the
Wormation supplied to the city as a part of this application.
SIGNATURE:
DATE
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PRINT NAME: Q pd e;
Bulletin #100 -January 1, 2011 Page 1 of 3 k:\Handouts\Permit Application
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