19-101181 CITY OF �..i ' .RECEI
A. PERMIT APPLICATION
Federal Way PERMIT CENTER+33325 8th Avenue South + Federal Way,WA 98003-6325
253-835-2607 + FAX 253-835-2609 +permitcenter@cityoffederalway.com
MAR 1 3 2013
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PERMIT NUMBER I C _ 1 efy�jy N�I D 0 JT� P1,
�1 !!! v 6T �"""„ I TARGET DATE
SITE ADDRESS SUITE/UNIT#
PROJECT VALUATION ZONING ASSESSOR'S TAX/PARCEL#
$ . et- 5 .5 s71o _ eics 67e>
TYPE OF PERMIT 0 BUILDING 0 PLUMBING 0 MECHANICAL 0 DEMOLITION 0 ENGINEERING FIRE PREVENTION
NAME OF PROJECT 1.. (C—il
( 44 L* Co
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PROJECT DESCRIPTION ��cc JJ
Detailed description of work to VtNk_ i_(✓ 7J . .
be included on this permit only
_..___,.. .-- - NAME 4 PRIMARY PHONE
l 64;c,Q-- 1,,deo<4 i.O. (;tf L-64:0 (,U-L 2 k5". IA t -iii 141 7
PROPERTY OWNER MAILING ADDRESS J E-MAIL
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CITY f-I{ L� 4.1��l It T& ZIP L V V - '- ------ - L V."Y
NAME �lyi 1/ k fr•)/) Ot(f :`_ PHONEk1vt C�
MAILIN ADDRESS l/ E-MAIL
CONTRACTOR
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CITY ,/ STATE ZIP FAX
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WA STATE CONTRACTOR'S LICENSE# EXPIRATION DATE FEDERAL WAY BUSINESS LICENSE#
NAME n Icc, Nt /cAPgce_fi,Y PRIMARY PHONE
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APPLICANT, MAILING ADDRESS E-MAIL
y . 1t X A if)(AI t{- 5,k,M C
CITY STATE ZIP FAX
-- - NAME '�- PRIMARY PHONE
PROJECT CONTACT L� ��t 1 `�_\� rj it lc
(The individual to receive and MAILING ADDRESS 17A E-MAIL �j
respond to all correspondence � � �� v
concerning this application) CITY STATE ZIP FAX
NAME
PROJECT FINANCING X 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 pity, including its officers and employees, upon the accuracy of the
information supplied to the city as a part of this application
•
SIGNATURE: V✓ L C U L DATE
PRINT NAME: ((- •1 L LL{'t-
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