17-103385 `mor to PERMIT ME PL DE EN FP
Federal Way R Eet E�
COMMUNI Y DEVELOPMENT SERVICES APPLICATION
253-835.2607•FAX 253-835-2609
uwJUL L , 2017
w .dAjorrederalway.com
WAY OF
SITE ADDRESS 5 , �+e�A1c[s r+ n d COMMUNITY DEVELOPMFNT SUITE/Mar*
GASIGRe-M6A839501 9k
Aye So_ Fere elwhy q', 3
PROJECT VALUATION ZONING R'S VAX/PARCEL t
$ ��d Pv 7 5 0 L 5`- - 0 O / D
TYPE OF PERMIT 0 BUILDING 0 PLUMBING 0 MECHANICAL
0 DEMOLITION ❑ ENGINEERING WFIRE PREVENTION
NAME OF PROJECT
(Tenant Name/Homeowner Last Name)
5r FcA4 e;j trio B - t14_D B - 2e1
4/4a re, A),
PROJECT DESCRIPTION A DD 3 24 024 s i /mss 1 3 s 5 2i mss, r1 A . PA,J c1 a- Aasaemia
Detailed description of work to $yvl211L A[Tee:2 T� -r i.. 5pA c e-
be included on this permit only
NAME PRIMARY PHONE
PROPERTY OWNER CATilvi2 e- /f rALZ)1 Jwl i I fAIiYW - 5T Ji1Afict5 ) 4)
MAHJNG ADDRESS E-MAIL
CITY STATE ZIP
Fell ezal i4A lAiA R Boi
NAME PHONE
c'1v>J1'teqid-r" 14')t1-ol�ifs LL fa5".-,slto4-la-77
MAILING ADDS
E-MAIL sets ,�r Gots uaP-9,7Air
CONTRACTOR V59 .1).1Ar i.icil Ave- S r - JDp 7 . Cary
CITY STATE ZIP FAX
�t*r
R' ) -w 4 9$(057 51?5" - 5/- (>4'01
WA STATE CONTRACTOR'S LICENSE M EXPIRATION DATE FEDERAL WAY BUSINESS LICENSE C
CPAIYFrLe-Le.4 13r _ 1 i iB HO ,, D•os•)Ga93R-oo BL
NAME PHONE
b)e, 544;7Il 01-5-3- ?3.Q-616,,z,
APPLICANT MAILING ADDRESS E-MAIL
5r4r1.e 143 ezo AciTQ
CIT! STATE ZIP FAX
PROJECT CONTACT NAME PHONE
4 individual to receive and. 5 A 7'4 e AS (7 ) 4G D Q
respond to all correspondence MAILING ADDRESS E-MAIL
concerning this application)
CITY STATE ZIP FAX
AI:ZEBRA=CONTACT NAME: PHONE E-MAIL
PROJECT FINANCING NAME o OWNER-FINANCED
Required value of$5,000 or mere
(RCW 19.27.095) MAnmG 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 Wag 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 thecity as a part of this application. ,,r
//L
SIGNATURE: �1 ) DATE 7-/7-/7
PRINT NAME: U'/t/✓tl) 5/1'rtZi ,
Bulletin#100-January 1,2011 Page 1 of 3 k:\Handouts\Permit Application