19-101025CITY OF RECEIVED PERMIT APPLICATION
Federal Way MAR 0 5 2019 PERMIT CENTER + 33325 8th Avenue South + Federal Way, WA 98003-6325
253-835-2607 + FAX 253-835-2609 + permitcenter(iicityoffederalway.com
CITY OF FEDERAL WAY
COMMUNITY DEVELOPMENT
PERMIT NUMBER _ 0 / 0 C Cs — r
��/ TARGET DATE
SITE ADDRESS/ 11 II
110Ll�w Opk,i NPLA, .5 ��1��
SUITE/UNIT #
10Z
PROJECT VALUATION
ZONING
ASSESSOR'S TAX/PARCEL #
$ C'��1
C� /� 2
1 J_
•
-5 6 �L/
TYPE OF PERMIT
❑ BUILDING ❑ PLUMBING ❑ MECHANICAL ❑ DEMOLITION ❑ ENGINEERING AFIRE PREVENTION
NAME OF PROJECT
PROJECT DESCRIPTION
Detailed description of work to
9- t&_ F, I ,i %46 i4 ' P2OQ0F
be included on this permit only
NAME,, ``^^
k /�4- LzA
PRIMARY PHONE
PROPERTY OWNER
MAILING ADDRESS
1 '7000 REb aILL- AV/
EMAIL
CITY
a7zo M E
STATE ZIP
CA �jZln�
NAMEV
2$q e. ) ti-
X253 - - 2300
MAILING ADDRESS , ! `
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E-MAIL
CONTRACTOR
CITY
STATE
S'W A
ZT
86. 1
FAX
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— 0 5 —2 3lo3
WA STATE CONTRACTOR'S LICENSE #
1,e "77 s'3
EXPIRATION DATE
FEDERAL WAY BUSINESS LICENSE #
Ela rel
! i 2
19-20- -00ry-8
NAME ^^
PRIMARY PHONE
APPLICANT
MAILING ADDRESS
E-MAIL
CITY
$TATE
ZIP
FAX
PROJECT CONTACT
NAME
�5 1A A(, j Lc— o tAP,(
PRIMARY PHONE
253— 639 - 42,M)
MAILING ADDRESS r \ l
ZN w 3Z O
E-MAIL
SraALaJ P JeRX fFtF eTP C,
(The individual to receive and
respond to all correspondence
CITYi\kAt ��Id
s TFA
't,U dy
zIP
Z7
FAX
concerning this application)
PROJECT FINANCING
NAME
❑ OWNER -FINANCED
When value is $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 arifes out of the reliance of the ity, including its officers and employees, upon the accuracy of the
information supplied to t i a part of this ap ication.
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SIGNATURE: DATE
, 1 �n 1�
PRINT NAME: Sl �1.31J t_ H 1' ` AN
Bulletin #100 —January 29, 2016 Page 1 of 2 k:\Handouts\Permit Application
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