19-101871 RECEIVED
APR 14 2019 PERMIT APPLICATION
CITY OF
Federal Way CITY OF FEDERAL.WRY PERMIT CENTER+33325 80h Avenue South+Federal Way,WA 98003-6325
COMMUNITY DEVELOPMENT 253-835-2607+ FAX 253-835-2609+permitcentertikityoffederalway.com
PERMIT NUMBER O "Y 1 1 (/I _ P J I jA
_b TARGET DATE 1
SITE ADDRESS SUITE/UNIT#
.ZO ZO 5 3 0t S fi i l
Q PROJECT VALUATION ZONING ASSESSOR'S TAX/PARCEL# � � -
$ `3 C/ ° 0 I Z
TYPE OF PERMIT ❑ BUILDING ❑ PLUMBING ❑ MECHANICAL r❑ DEMOLITION 0 ENGINEERING s�PIRE PREVENTION
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NAME OF PROJECT f Bye _ ,..
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PROJECT DESCRIPTION
Detailed description of work to -(,tr4 Afvf i- 7�r
fl) jf Sp,
be included on this permit only
NAME 1 �� GUP � R- P�147-/A-
PROPERTY
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PRIMARY PHONE
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PROPERTY OWNER MAILING ADDRESS E-MAIL
CITY STATE ZIP
NAME C !lir I SC{V 4�'Q ) rRONE�O -34 7 —if7
MAILING ADDZ-MIL
CONTRACTOR to, q _3 , h a re I ch 51 Aa l eSM4.V.Gh,
CITY
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f -1-4 LA)
k STATE ZIP
�j /i 07 FAX
WA S�TA'l'�CONTRACTOR'S
A S .e a✓o ki r,rI� yP� Z+2- / ) / VO_It ATION DATE _ FEDERAL�A0bei(7 -to-- V'
y1�1°(I,(l�/�7/ �I yJ n PRIMARY PHONE
APPLICANT MAILING ADDRESS E-MAIL
CITY STATE ZIP FAX
MARY
PROJECT CONTACT NAME /--�°r°1 d I3.Q i yZ p(, �c j/ �' 3 3
(The individual to receive and M l��I e 9 S 3 r ry�l o$t)'iia/pyp,.,,,,f1%ti,
respond to all correspondence U / Its V 1
concerning this application) CITY ' Hie sTAT,F, Z{>;2a DA FAX
a 771 �� T _/
NAME
PROJECT FINANCING 0 OWNER-FINANCED
When value is$5,000 or more 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 a part of this application. 1 q
SIGNATURE: if, DATE / /1 7 / / /PINT NAME: ra Ie V2L/S
Bulletin#100—January 29,2016 Page 1 of 2 k:\Handouts\Permit Application