19-102189 �
>> ,� PERMIT APPLICATION
CITY OF MAY C s�C�,.�
PERMIT CENTER+33325 8th Avenue South +Federal Way,WA 98003-6325
Federal Way cm( - ; -; - y WAY 253-835-2607 + FAX 253-835-2609 +permitcenter@cityoffederalway.com
COMMUNITY DEVELOPMENT
PERMIT NUMBER Q _ V _ � TARGET DATE .
SITE ADDRESS !!! SUITE/UNIT#
2000 S, —3({(k 9€ck)
PROJECT VALUATION ZONING ASSESSOR'S TAX/PARCEL#
$7 Zb ( 2 U - O 2z (
TYPE OF PERMIT ❑ BUILDING 0 PLUMBING ❑ MECHANICAL 0 DEMOLITION ❑ ENGINEERING If—VIRE PREVENTION
NAME OF PROJECT u
—Cv1. 21
PROJECT DESCRIPTION 2 ��\��
Detailed description of work to
be included on this permit only
_
NAME _ PRIMARY PHONE
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PROPERTY OWNER MAILING ADDRESS E-MAIL
CITY STATE ZIP
--- NAME - - - - ---- PHONE
1MAILING ADDRESS f•-•-k
'`� x E-MAILr P
CONTRACTOR '� t�� (.sap, Q " ie icvt
CITY STATE ZIP FAX
1\S:>, , n W.".` V 9 cS3,I
Wb`MCONTRACTOR'S
LICENSE#
t'J1cA-1cc Lk') �o cxP
j / N FEDERAL 70 q —loo LICENSE( OU6L
NAME PRIMARY PHONE
z2- ')5(s-
APPLICANT
) (SAPPLICANT MAULING ADDRESS E-MAIL
Q e , Cs,1-\
CITY STATE ZIP FAX
NAME PRIMARY PHONE
PROJECT CONTACT Q
(The individual to receive and MAILING ADDRESS E-MAIL
respond to all correspondence
concerning this application) CITY STATE ZIP FAX
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 as a part of this application. /
SIGNATURE: DATE 5/01/9PRINT NAME: C�� t 0 k SI'r) tY 11
Bulletin#100—January 29,2016 Page 1 of 2 k:\Handouts\Permit Application