19-103017 I, RECEIVED PERMIT APPLICATION
CITY OF .011
Federal Way JUN 21 2019 PERMIT CENTER+33325 8th Avenue South+Federal Way,WA 98003-6325
253-835-2607+FAX 253-835-2609+permitcentelfa)citvoffederalway.com
(QTY OF FEDERAL WAY
�
j 0 COMMUNITY DEVELOPMENT
`
PERMIT NUMBER l _ _ 1 3 0 / - f ? /U//9
TARGET DATE
SITE ADDRESS SUITE/UNIT#
3S22.. 21s= , Suo Fe-1±191„k u3cLA C 8003
PROJECT VALUATION ZONING ASSESSOR'S TAX/PARCE
$ Ilq-9•,l 25 2 1 0 3 _ cl0 s' 0
TYPE OF PERMIT ❑ BUILDING 0 PLUMBING 0 MECHANICAL 0 DEMOLITION 0 ENGINEERING IF.FIRE PREVENTION
NAME OF PROJECT 14)"t► SIA nomJ 2e) \ c &--
PROJECT DESCRIPTION ` &Ai, Ca/01(24e ealet4WIVIcilw.,
Detailed description of work to //
be included on this permit only
NAME PRIMARY PHONE
'e_14e Q IAA as3 a3o OM 12
PROPERTY OWNER „ES
E-MAIL
1?c o C�c. s 74 �f I•Ueeal1.e>On�u I
rle�a,� A ZIq BvIJ3
NAME
PHONE
`SPD) t vPc �,c . _53 ga91
MAILING •DRESS E-MAIL p Sovnd
CONTRACTOR A l 0 r "' ` IA E it I 1I _ ,
CI Ia.COPM-• T. ? ZUtall(Q� FAX
y'34SS2
WA STATCONTRACLICENSE NEXPIRATION DATE FEDERAL WAY BUSINESS LICENSE N�� DtP � Tv
NAME PRIMARY
PHONE
-Ikt Han nit k 9 v3 8- 2/9-1q
APPLICANT MAILING ADDRESS E-MAIL Swrd
-�7` Sqll ogch f- W jjUyy n ESI tnAl kaki j e ser-0114hp ela
C 4`v` tkVt t- 1//_J 'ATE ZI- la`-,c' FAX
ca. Liss 2_
NAME �C PRIMARY PHONE
PROJECT CONTACT exa n FferflMinj g 3 8%3. -Ii(
MAILING ADDRESS J E-MAIL
(The individual to receive and 'l th
V
respond to all correspondence 9// o .4UA% 5 — IN fRt'iHNNIN�g .Setttlet IV V.Ore
concerning this application) CITY STATE ZIP FAX L/
�e,rrr� u% &9- c9S3 1-115L1ss2_
PROJECT FINANCING NAME /UI/i
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 as a part of this application.
•` , • /
SIGNATURE: 111/11 /M /�
PRINT NAME: eL rte"Vnt"3
X
Bulletin#100-January 29,2016 Page 1 of 2 k:\Handouts\Permit Application