19-102628 RECEIVED
CITY OF JL n' 3 2019 PERMIT APPLICATION
Federal Wa C�TY OF FEDERAL WA`( PERMIT CENTER+33325 8th Avenue South+Federal Way,WA 98003-6325
Y COMMUNITY DEVELOPMENT 253-835-2607+FAX 253-835-2609+Dermrtcenteifdcity�offederalway�.com
PERMIT NUMBER _ / _ Ee (
TARGET DATE S
SITE ADDRESS S.L SUITE/UNIT C
2,5C)S 320,E r?3
PROJECT VALUATION ZONING ASSESSOR'S TAX/PARCEL Il
T 2cIy9 I C? G, - 0 G 5
TYPE OF PERMIT ❑ BUILDING 0 PLUMBING 0 MECHANICAL 0 DEMOLITION 0 ENGINEERING FIRE PREVENTION
NAME OF PROJECT PLA c-- C77" ,D Pee>Q ^ ceK.01,N)
PROJECT DESCRIPTION e ' EX��, *"<. 12, AP> ,c e-9 ,0 7'1. L A-Y�k1 —
Detailed description o work to �
be included on this permit only 15,R,-'�G s�.4
NAMEPRIMARY PHONE
prv'
PROPERTY OWNER MAILING ADDRESS E-MAIL
Zel5 S2.4371,4CITY
'S
eOte./){.. %JOp ZIP g, 5,
NAME PHONE
4C-e- 1►j?...e •5-r it4LL.e ZI96-4' 34-- 111-s
MAD./KNG ADDRESS E-MAIL
CONTRACTOR g&))( Zalo� Q AsEgp'2tz5' S*45ee�'l 'x Mt').
CITY FAX
524
WA STATE CONTRACTOR'S LICENSE N EXPIRATION DAT& FEDERAL WAY BUSINESS LICENSE N
AcGA )4c0$n1 12, 3! J7
NAMES PRIMARY PHONE
APPLICANT MAILING ADDRESS E-MAIL
CITY STATE ZIP FAX
NAME PRIMARY PHONE
PROJECT CONTACT
(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 authorised 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 ty pari of this application. / �y
SIGNATURE: / (�/ DATE —
L
PRINT NAME: / �^f/l ,�
�t d lig 'I" L -
Bulletin#100-January 29,2016 Page 1 of 2 k:\Handouts\Permit Application