19-100598 _....._ _A. PERMS i PPLICATION
CITY OF
MIT CENTER+33325 8th Avenue South +Federal Way,WA 98003-6325
Federal Way PER253-835-2607 + FFEB*55 +perniitcenteracityoffederalway.com
CITY OF FEDERAL WAY
I G1 -
I C) 0 CJ C g _ f ?COMMUNITY DEVELOPMENT f+--
___
�PERMIT NUMBER t V T /tJJr,
TARGET DATE
SITE ADDRESS
SUITE/UNIT#
3500ZZ jGG 0kA) v, U - f�S
PROJECTVUATION NING / ASSESSOR'S TAX/PARCEL
$ )006 , d 6 1 5 1 5 _ e 0 0
TYPE OF PERMIT ❑ BUILDING ❑ PLUMBING ❑ MECHANICAL D DEMOLITION ❑ ENGINEERING Igt FIRE PREVENTION
NAME OF PROJECT ,.-1e- g v\ ge ( ; e-P-
PROJECT
DESCRIPTION i^� ' 4r / „ S
Detailed description of work to iC�►1 K-�+
be included on this permit only
NAME PRIMARY PHONE
CJea. 2- Pek:,1 ge-i:e42--
PROPERTY OWNER MAILING ADDRESS E-MAIL
CITY n` STATE ZIP
-- .. .... . NAME Pe_e. A `,`1 L z 1 S)to,e} ` 1.--1-C..— PHONE CJ4, 3 1 ( 1175
MAILING ADDRES / v Jn E-MAILCJ.
CONTRACTOR Vs 0,r,✓L (9.S)
9. SGs Q r1 6c7&/c L,c,sl
CIle-Y STATE,. ZIP i,,g-S`-1 FAX
W.I. T CONTRAC 'S LICENSE# w EXPIRATION DATE FEDERAL WAY BUSINESS LICENSE#
AC`sE els C9 A 3
NAME ( - / „F - P�YPHONE
36056/0 '.l S 7
APPLICANT MAILING DAD_%D\RES 9h//-/�j/T{/�C/�J/ E-MAIL
r, o, goy -fieS
CIT.V �e S"`�TATB Z�V>Z 1 FAX
NAME (� 1 �� PRIMARY PHONE
PROJECT CONTACT 131 A c 14—/4- -' 0LC)(� 3H1)75
(The individual to receive and MAILING ADDREs 0 + 6 ‘S I MA4 )36`rsiy��` a
respond to all correspondence / (�fJ`i�)
concerning this application) CIT p A .
ZIP �2 FAX
t�
NAME4 1.✓ ,,,,.�,, �
PROJECT FINANCING IJ- NER-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 o ‘ application.
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SIGNATURE: d DATE —S /
PRINT E: 1415
Bulletin#100-January 29,2016 Page 1 of 2 k:\Handouts\Permit Application