19-103212 CITY OF .
_ .A.
R= :i-v-La ERMIT APPLICATION
Federal WayERMIT CENTER+33325 8th Avenue South+Federal Way,WA 98003-6325
JUL 0 2019 253-835-2607+FAX 253-835-2609 +permltcenterAcityoffederalway.com
C!jCITY E WAY
PERMIT NUMBER67 _ / _ r �J
TARGET DATE `
SITE ADDRESS SUITE/UNIT#
a SOS 5 3a0t" Sr «- . c^,.1
PROJECT VALUATION ZONING ASSESSOR S TAX/PARCEL#
TYPE OF PERMIT 0 BUILDING 0 PLUMBING 0 MECHANICAL 0 DEMOLITION 0 ENGINEERING FIRE PREVENTION
NAME OF PROJECT K i 01 U)i +-
PROJECT
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Detailed description of work to (\GLA) (:),. 1 L( �\ ,kel' Q.) p^\ -cUJ0rS 3- s, c \o c.k,-C
be included on this permit only �"
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NAME PRIMARY PHONE
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PROPERTY OWNER C '\ n' 7� (P.�Ltc LLC-
MAILING ADDRESS E-MAIL
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CITY STATE ZIP
NAME PHONE
MAILING ADDRESS A c5 isV-
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CONTRACTOR Sa [..S t.M�1br/n /tk/I, s{7-Gl V,S E'�f1(' @c CtStf1 C�C-44 '0CITY 1 STATE ZIP AX j
kiliq. W ik Cft'3,L.
WA STATE CONTRACTOR'S LICENSE 8 EXPIRATION DATE FEDERAL WAY BUSINESS LICENSE#
p I,.S E1V Eti as lQ l_ / /
NAME PRIMARY PHONE
. z a s COO'.i -
APPLICANT MAILING ADDRESS E-MAIL
CITY STATE ZIP FAX
-- NAME - J - - - - -- -- PRIMARY PHONE - -
PROJECT CONTACT 30 r (5)r lxtr/ 075-3-e72--(oar
(The individual to receive and MAILING ADDRESSsAkieE-MAIL
respond to all correspondence S t-Shsty v b - -Gl ` ,IV11S1-t1( jeC (�'te•Gk1t,,'het
concerning this application) STATE ZIP FAX
(�
ll� _ DIY CI), - -
-- - — NAME --- --
PROJECT FINANCING �'---- ❑ 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 ci m arises out of the reliance of the city, including its officers and employees, upon the accuracy of the
information supplied e city as a art of this application.
_ ( f /
SIGNATURE: ` DATE (
PRINT NAM 305 6-/aini'L(rrG�
Bulletin#100-January 29,2016 4J` Page 1 of 2 k:\Handouts\Permit Application