19-103449 1 1 _ ) 0 5 14 tit 7 02
CITY OP
Federal Way PERMIT SF MidI�r c Er /ED DE EN FP
COMMUNITY DEVELOPMENT SERVICES APPLICATION C L�C t V C
253-835-2607•FAX 253-835-2609
www.atuoffederalwau.com JUL 1 8 2019
CITY OF FEQERAL WAY
SITE ADDRESS
COMMUNITY D1111123 MJ1
10tq 5 35 I St 57
PROJECT VALUATION ZONING ASSESSOR'S TAX/PARCEL#
$
-71ooO
2 0 � t U H - 4 n 24
TYPE OF PERMIT ❑BUILDING 0 PLUMBING 0 MECHANICAL
0 DEMOLITION 0 ENGINEERING olg FIRE PREVENTION
NAME OF PROJECT /'�
(Tenant Name/Homeowner Last Name) T. I 3 98 - o cC CC_
PROJECT DESCRIPTION ri'^5 h►II;.") FASS C i`rt aid./).4. c�u:'•ce 4` r
Detailed description of work to ri!__ 042-Pi't 4 -'txid i 4-
be included on this permit only
NAME PRIMARY PHONE
PROPERTY OWNER
NeaVhe.lPr Ftig?neet`lr) ='nC 23� - gS-�'/- 3G 3S
MAILING ADDRESS J E-MAIL
22 10 $BILI at12
CITY Kev)4- Sura �f903I
NAME PHONE
at Sett &ter1r•c ..77/c ZS3 -072-Igor
MAILING ADDRESS E-MAIL
CONTRACTOR 32 S' WAS In n1 fon iittit, 5 '1f TR r as @ e/;.n>-, 6/echIC.Pvt.f-
CITT ST�i4 } u ZIP f9O,32 FAX
tr1
WA STATE CONTRACTOR'S LICENSE♦ EXPIRATION DATE FEDERAL WAY BUSINESS LICENSE C
Omen 6. (131 PF 1D / S aelit
NAME PHONE
2.4 Oa", 51..0; z5-3—$7z-14'd -
APPLICANT MAILING ADDRESS E-MAI'
32 r M.aasI;,,,9tor, 5At.ef I
CITY STATE ZIP FAX
K e)~t- >A_)a, 4/603 1
PROJECT CONTACT NAME PHONE �e^
(The individual to receive and 6r 1`C 5105 S ZS2 ' J
3 —87
!4Q
respond to all correspondence MAILING ADDRESS E-MAIL
concerning this application) 32,5" toq.5 h Srl fort Aix. ,fVCITY ,/ STATE ZIP FAX
KCO I-- IAA *3011
ALTERNATE CONTACT NAME: PHONE E-MAIL
PROJECT FINANCING NAME
0 OWNER-FINANCED
Required value of$5,000 or more
(RCW 19.27.095) MAILING ADDRESS,CITY,STATE,ZIP PHONE
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 part of this application.
SIGNATURE: --- .7,-,,,gr --' DATE 7// T 2
/ZD/9
PRINT NAME:_A/4 N .St.•.,119''/A—
Bulletin
fiBulletin#100—January 1,2011 Page 1 of 3 k:\Handouts\Permit Application