19-103206 e.,.. .‘ „
CITY OF �..�-- q
PERMIT APPLICATION
�ul 9 2019 PERMIT CENTER+33325 8th Avenue South+ Federal Way,WA 98003-6325
or
Federal Way 253-835-2607 + FAX 253-835-2609 +permitcenter@cityoffederalway.com
CI i'i'0'H 'rEDEPAL W,W
VI
PERMIT NUMBER ' 1 / �V 4
- - TARGET DATE
SITE ADDRESS SUITE/UNIT#
3(000 s 3uC(4 3,i--'
$ PROJECT VALUATION ZONING ASSESSOR'S TAX/PARCELM � � � _
/9-17-- 7 _ __ —
TYPE OF PERMIT 0 BUILDING 0 PLUMBING 0 MECHANICAL 0 DEMOLITION 0 ENGINEERING 0 PREVENTION
NAME OF PROJECT '--- ---
71
PROJECT DESCRIPTION �// _ „_�c��•+
Detailed description of work to ( -J j(J;! -----112:<":"
be included on this permit only
NAMEPRIMARY PHONE
_
PROPERTY OWNER 61'13_ ��5,-;--
BLAMING ADDRESS < ..13 ,.._�---fr—`- E-MAIL
CITY STAT ZIP
NAME 4
,/) ,(� n PHON � 6/
MAILING ADDRESS �� / _ E-MAIL7
CONTRACTOR S� � J � � �� r I Ili _-�/'�G Cj 12d:e /f -
CITY � STATp ZIP FAX --62;7-
72
1>y/�i-1 / I/. Apt i„=Z fe) ` -E
WA STATE CONTRACTOR'S LICENSE , EXPIRATION DATE FEDERAL WAY BUSINESS LICENSE#
c1 j/ .�1/c ir7, / / •
_
NAME PRIMARY PHONE
. .4i2 f9S 11°Y�i
APPLICANT MAILING ADDRESS E-MAIL
CITY STATE ZIP FAX
-- .
NAME _ PRIMARY PHONE
PROJECT CONTACT y(i,-, /1-_-..5 /9 -v-
(The individual to receive and MAILING ADDRESS E-MAIL
respond to all correspondence
concerning this application) CITY STATE ZIP FAX
NAME
PROJECT FINANCING 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 c •im), which may be made by any person,including the undersigned, and filed against the city,
but only where such claimses • t of tom- reliance of the city, including its officers and employees, upon the accuracy of the
V
information supplied to t ty •- a part• this •pplication.
4_-----
1 C7
SIGNAT ;--• : _' �� — __ - DATE //'?
7,-� y
PRIN AME: J��. &2220
Bulletin#100—January 29,2016 Page 1 of 2 k:\Handouts\Permit Application