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19-102478
11 A RECEIVED CITY OF ^...,� MA 21 2 PERMIT APPLICATION PERMIT CENTER+33325 8th Avenue South+Federal Way,WA 98003-6325 Federal Way CITY Or FEC 253-835-2607 +FAX 253-835-2609+pexmitcenter©cityofederalway.com CAMMUNf7Y DE'I/E �U�Y OPMEp- PERMIT NUMBER_E--c _. 1 0 2 .7 - r e TARGET DATE SITE ADDRESS SUITE/UNIT iE 7\010' '1 3a Id al el / 50) Y71415 t 3 PROJECT VALUATION ZONING' ASSESSOR'S TAX/PARCEL It G TYPE OF PERMIT El BUILDING ❑PLUMBING ❑MECHANICAL 0 DEMOLITION 0 ENGINEERING OFIRE PREVENTION NAME OF PROJECT .Q (p Cr4 NA- iJ c P 2 ` s PROJECT DESCRIPTION f k, ck cur 66�-A2 ., ( AckUnc�( Q v l`e Detailed description of work to be included on this permit only • NAME '�A_- \ PRIMARY PHONE PROPERTY OWNER `�_ DA- `'"" �T\k`i V�l Q22-142.10 LING ADDRESS E-MAIL • Y �f,\CEO- Wa9 O !X 7 i.lA��/_XX. y�Ko �AME HONE AVACU AI .5eCJAV l• ` x0(j) .) [01 -2c; P r&ek)A6eakv k 3•W MAILING''"`INADDRESS / CONTRACTOR \ l"[3 1 ` `� 4. CITY `STATE ZIP FAX ,WA STATE CONTRACTOR'S LICENSE it EXPIRATION DATE FEDERAL WAY BUSINESS LICENSE Y .-AIA � ) 7, , q ��> N--Mr --Dl>-c-NI_ +tn I CWOV \‘i'n'n a`n NAME - PRIMARY PHONE [i `'l�r�PLIVMC vANvCT!••\•w MAILING ADDRESS E-MAIL 3Ucc cw•5ecv r� . \"tom i -Ave.5 �_ CI - 9TA E _,ZIP k_ FAX - C`AM (`y�(jy� NAME �-- IIMyARY PHONE1 �,,t / PROJECT CONTACT W P�. `-0/ If V\,O Vl r/�.(0621S— �S`-t,9 (The individual to receive and MAILING AADDR> V MAIL respond to all correspondence l V ?) \ rye •) concerning this application) CITY E �P FAX ai.t. ....i..„ PROJECT FINANCING NAME El 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 fired 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. SIGNATUREt k Ult. DATE . 01 v , .. PRINT NAM: _.AIA.. ° ° • -Ull_ LA Bulletin#100—January 29,2016 Page 1 of 2 k:\HandoutsWermit Application