19-103334 RECEDED
„,,„,,A,CITY OF JUL A I 2019
PERMIT APPLICATION
Federal Way PERMIT CENTER+33325 8th Avenue South+ Federal Way,WA 98003-6325
QI I Y QF FEDERAL WrrY 253-835-2607 + FAX 253-835-2609 +permitcenter@cityoffederalway.com
CO►�AMUNITY DEVELQP'MI
IZ
PERMIT NUMBER
l � _ 0 3 3 9 -3 III I^ ? N /4-
____ TARGET DATE
SITE ADDRESS SUITE U IT#
3C16, i 6 ) 1# - PL, rJer,i wl', w� , ���
PROJECT VALUATION ZONING ASSESSOR'S TAX/PARCEL#
$ 3x00 z Is y -7 0 _ 0 0 •7 O
TYPE OF PERMIT 0 BUILDING 0 PLUMBING 0 MECHANICAL 0 DEMOLITION 0 ENGINEERING LK N'IRE PREVENTION
NAME OF PROJECT Dr, G
PROJECT DESCRIPTION
Fr...t.,'c
e- Pc-i�C_Gf"S F'4 --Detailed description of work to % VI•LG ce
P
r', fa „-•d-nF F,4.
be included on this permit only De 1,1, S
NAME PRIMARY PHONE
PROPERTY OWNER MAILING ADDRESS E-MAIL
CITY STATE ZIP
NAME i-. r C,EJ 4,''` C ,bi,•Qy PHONE�2 .-- d`
3/7- 'J /
MAILING ADDRESS E-MAIL
CONTRACTOR 3G ici H 0 Y/- /fvL *,,'i-iAcc ,(1 4,�G,4-.&,n-1
CITY STATE ZIPFAX
GL4(r. f--1- i et$.20(I
WA STATE CONTRACTOR'S LICENSE# EXPIRATION DATE FEDERAL WAY BUSINESS LICENSE#
SEACOCICt /'-!Do 3 / /c;7o
NAME PRIMARY PHONE
APPLICANT MAILING ADDRESS E-MAIL
CITY STATE ZIP FAX
NAME PRIMARY PHONE
PROJECT CONTACT If O Y ���n S v r1 4/2,5,--31 7 - 8'2 S"cr
(The individual to receive and MAILING ADDRESS J E-MAIL
respond to all correspondence 3i�I U 1 !CPY r '�_ �JU*4 Son�CQ)1 sece_06,4.0N
concerning this application) CITY STATE ZIP FAX
6,1,
-
9
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 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 •• - •.-his application. ) C�j
SIGNA - • �'— DATE f `1 /
PRINT NAME: SS C-- Cc.('(`
Bulletin#100–January 29,2016 Page 1 of 2 k:\Handouts\Permit Application