19-103024 C17YO
411t11/1`. UN PERMIT APPLICATION
FederalJUr 2 1 2019
Y Y PERT CENTER+33325 8th Avenue South+Federal Way,WA 98003-6325
253-835-2607+FAX 253-835-2609+permrtcenter�)cltyoffederalway.com
T
CC�,i:iUr;lY Dtr'VEL CPMEiPERMIT
--- \_. /
PERMIT NUMBER / _ /
3 0 _ TARGET DATE
SITE ADDRESS ' SUITE/UNIT#
2O Z 0 S 3 2_0 5/-- Z-g' 'I J D l
PROJECT VALUATION ZONING ASSESSOR'S TAX/PARCEL#
$ /C'06 - - — — —
TYPE OF PERMIT ❑ BUILDING ❑ PLUMBING ❑ MECHANICAL 0 DEMOLITION 0 ENGINEERINGg IRE PREVENTION
NAME OF PROJECT
note(
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PROJECT DESCRIPTION �wA �o r a q � 1/ c� 'x �� -f
/ Detailed description of work to /T1"'d Cj wi)'a''C S S,a, mo chi.. i� At,,, (et a u✓o_f
be included on this permit only
NAME PRIMARY PHONE
PROPERTY OWNER MAILING ADDRESS E-MAIL
CITY STATE ZIP
NAMEPHONE
,I7
(If h a S2Y-4 t`ce S 24.6—36 y -11 9 8
MAILING ADDRESS ''j 7 E-MAIL
CONTRACTOR Q O
CITY 5:2" H-(R STATE2I�b_'oQ
VP AF FAX X
*TATE CONTRACTOR'S
wICsk�Ly5eeCO '01314 6i1Z, 1 7Ws1L ( 0Coge 00 ►
NAMEPRIMARY PHONE
APPLICANT MAILING ADDRESS E-MAIL
CITY STATE ZIP FAX
NAME PRIMAR PHONE
PROJECT CONTACT /.- o(0( `{S ZD 6 9`F / 633 3
(The individual to receive and MAILING ADORES 04
_ E-MAILMw
respond to all correspondence z J �1 Q�Id's i7Ka,( �Q n ai lI.cA
concerning this application) CITY 4 _i(J ST T4 ZIP Q I a 11 FAX
NAME �ID V/1�'! 1 1
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 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 cit a part of this application.
SIGNATURE: DATE c (LI (Ip/PRINT NAME: f-Iarc/4� I3L l c
Bulletin#100-January 29,2016 Page 1 of 2 k:\Flandouts\Permit Application