19-103408 „,„,....4. A !r-
PERMIT APPLICATION
CITY OF
Federal Way juL I 13 „�
21)19 PERMIT CENTER+33325 8th Avenue South+ Federal Way,WA 98003-6325
253-835-2607 + FAX 253-835-2609 +permitcenter@cityoffederalway.com
CITY CF FEDERAL WAY
1 COMMUNITY DEVELOPMENT
PERMIT NUMBER 1 O (.4 0 _ FFick
TARGET DATE /1/4-) /
SITE ADDRESS SUITE/UNIT#
.721 (5 )efie von Ile ; b cw el. tA)Oy 5 €# (0/
PROJECT VALUATION ZONING ASSESSOR'S TAX/PARCEL#
$ c43 0 9 z- 1 CD CI - 7 3 a 2
TYPE OF PERMIT 0 BUILDING 0 PLUMBING 0 MECHANICAL 0 DEMOLITION 0 ENGINEERING L7 r'IRE PREVENTION
NAME OF PROJECT ??BGL G61xKen
Fwd fr1 a dente S 1. ei rste,$. SySfe•
PROJECT DESCRIPTION ...
Detailed description of work to
be included on this permit only
_ NAME PRIMARY PHONE
til A QeLAM $kAt-f I Y
PROPERTY OWNER MAILING ADDRESS E-MAIL
5o2 P d, &vat
CITY STATE ZIP
A-I9Oiu` wa 5806I .
NAME IL PHONE
Pro'tectrorl servo
MAILING ADDRESS E-MAIL
CONTRACTOR ?O �)( 3t If 1
CITYa� e �� STATE ZIP n FAX
4 IAA 618
WA STATE CONTRACTOR'S LICENSE# EXPIRATION DATE FEDERAL WAY BUSINESS LICENSE#
P ito TE -H $1q ICS 1C) />3.20 A-ppt c '`sy‘ -i i)w I /et
NAME PRIMARY PHONE
AFI ely GSA X53-348- 3331
APPLICANT MAILING ADDRESS E-MAIL
o 6 we 3`t I I ?refection Serwrc..
CITY _ STATE ZI� Lig c FAX I.`cowl
LjocktiNv
NAME✓' PRIMARY PHONE 4
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
ail 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 city as a part of this application.
r
SIGNATURE: / DATE r/ /6 / T-1
PRINT NAME: H�y G
Bulletin#100—January 29,2016 Page 1 of 2 k:\Handouts\Permit Application