19-103263 RECEIVED
JUL C. S 2019 PERMIT APPLICATION
Federal Way
( J -= WAY
GOMMukiTY DE ELOPMEtff
PERMIT NUMBER , _ I tV5v _ TARGET DATEAi/A-
- -
SITE ADDDRESS S 3 (-4.)A SUITE/UNIT#
'5O'5 '3TION 2O ' 6 INGFe4erASS S TAX/PARCEL9 oo�
$ a83 7. 85 7 9 '7 8 2 o - o 5• 3 S
TYPE OF PERMIT 0 BUILDING 0 PLUMBING 0 MECHANICAL 0 DEMOLITION 0 ENGINEERING LTJ HIRE PREVENTION
NAME OF PROJECT f .,* -' .. 3r4 y}h*5" F(ooas
PROJECT DESCRIPTION � ►locos 6'1'
eigA111a sor,Nla -' "�' e
Detailed description of work to OVCAlll`
tele a 4S
be included on this permit only
NAME PRIMARY PHONE
PROPERTY OWNER
MAILING ADDRESS E-MAIL
CITY STATE ZIP
PHONE
AME
NAtrY 'tf r- COnciruGhdn (r1C. 253-872•'7 7.2'2
MAILING ADDRESS E-MAIL
CONTRACTOR 7855 6 ZO(. h 5'&
CITXSTATE ZIP� O'2.
FAX
earl-
WA STATE CONTRACTOR'S LICENSE# W EXPIRATION DATE FEDERAL WAY BUSINESS LICENSE#
Piet s2A°t1 OCT/ 1 /2O1' 20-ow-1o/44/3- 4c
N LPRIMARY 5t Adt i 2W 71-PHONE
6{O#Z
APPLICANT MAILING ADDRESS E-MAIL
J IT &»®arth,ernsl- •
CITY STATE ZIP FAX r` I•GAl
Nam PRIMARY PHONE
PROJECT CONTACT 'lphile tuSGYx
(The individual to receive and MAILING ADDRESS E-MAIL ra •
6 ZCX * b_respond to all correspondence 7855 VindraOomilsereo irtari
on
concerning this application) CITYKevit STATE ZIP FAX •can
NAME
PROJECT FINANCING 0 OWNER-FINANCED
Required value of$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 th ity as a part of is application. q,
SIGNATURE: DATE 7// di•
PRINT NAME: X L C. "64ofr?
Bulletin#100—January 1,2013 Page 1 of 3 k:\Handouts\Permit Application