19-102952 illi.
RECEIVED
i
JUN 2'19 PERMIT APPLICATION
CITY OF n +�
Federa I Way - = , PERMIT CENTER+33325 8'h Avenue South+Federal Way,WA 98003-6325
01 Tr _ L WAY 253-835-2607+FAX 253-835-2609+permitcenter@cityoffederalway.com
COMMUI'1i; ,�LOPMENT
PERMIT NUMBER /9_ / 0 2 9 5 al _ r TARGET DATE —7 - 1 - / ci
SITE ADDRESS �� � ( �r i"/,lj._ /v�� �/ SUITE/UNIT 1i
2, 1 I S . '3Z�� (� L, /I ! 0
PROJECT VALUATION ZONING ASSESSOR'S TA*7PARCEL#
$ 1 01 D b Cji Z (4 S 0 I - 0 0 S—
TYPE OF PERMIT ❑ BUILDING 0 PLUMBING 0 MECHANICAL ❑�DEMOLITION 0 ENGINEERING
XPIRE PREVENTION
NAME OF PROJECT Pu(1 c4 -VRA l 2e wi�� Ij✓ ,\,,,, ,,4--( Ft. )f�5
r/6Z IN
PROJECT DESCRIPTION Le �[[J �(4 L �, ' � 1 °� S I _ Gf'L`S(Stsc /
Detailed description of work to C�'`�� 1 S , ✓k �6tS �1/t,' + kc'`"e -f `l
be included on this permit only c t�4 e 1�EcC.."c C� `r.( n� 'A` L( Cc) V lye
NAT `' F rR[RARY PRoxa
PROPERTY OWNER I I U�R�B� I 4\40111�1/f S 7� 4S �L�
MAI 1 GAD all / J 4 L dac,
NAMEPRONE
us L
MAILING ADDRESS E-MAIL
CONTRACTOR
CITY STATE ZIP FAX
WA STATE CONTRACTOR'S LICENSE# EXPIRATION DATE FEDERAL WAY SUSINESS LICENSE i
/ /
NAME[3
/i(.. lr 4 ,4 V\I-
fe`7 S ;� `( S.-cal
ONE
AIL
APPLICANT MI GAD 3 Z 4, ' VI > 1 (t! 6126
hcj ( ("1/4 y STT
T 7 g a7,
FAT1 6) (1.S"-c-`i ni
NAME PRIMARY PHONE
I
PROJECT CONTACT ( I I I
(The individual to receive and MAILING ADDRESS E-MAIL
respond to all correspondence (( ( ) ( /
concerning this application) CITY STATE ZIP FAX
f i
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 authorised 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 authorised 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 • ade by any person,including the undersigned,and filed against the city,
but only where such claim arises out of the relian - ', the city, including its officers and employees, upon the accuracy of the
information supplied • the city as a part . this app
i� / t.
SIGNATURE: - /
DATE 6 — ' `
PRINT NAME: ,r'1 C-V\ / 7-e
I
Bulletin#100—January 29,2016 Page 1 of 2 k:\Handouts\Permit Application