10-103192 cEivE- 1111
CITY
OF' PERMIT
Federal vta�y SF MFFMCO ME PL DE E FP
�ERA�. South K;�a� i•°�s e & Rescue
co2M8' l P� 1 $YI'LICATION wv)v ed
wu•w cdnolfederalwau corn CDS E. AySIcta11Sd
O-Subjoct to lAt:'c, Lr ..D..=:�
SITE ADDRESS SUITE/UNIT X
Som S, 336 5 7'. By- � --- --d-- -4:).0--r-
PROJECT VALUATION ZONING ASSESSOR'S TADHABCS --/ Gl
$ 3,000 -
TYPE OF PERMIT ❑BUILDING ❑ PLUMBING 0 MECHANICAL
0 DEMOLITION 0 ENGINEERING/ X FIRE PREVENTION
NAME OF PROJECT I (/�1
)
(Tenant Name/Homeowner Last Name) j_(Jf,6/2, tiz G
PROJECT DESCRIPTION +- ii
Detailed description of work to f/� Alto i'+, -j , Ct,Y/ilc,ar- IC-' '7 Y
be included on this permit only
NAME1 PHONE
PROPERTY OWNER l� (�( (J (}' /� 778( )C-5-7-
- /2�..-
MAILING ADDRESS __ -�
/jig
Cil
la „b'act nriA STATE ZIP
NAME Pry —i l,7 a I1--r/c- I)- c PHONE i 2 $' - 3 3 Y '18 Y V/
MAILING ADDRESS
Q '/ E-MAIL
CONTRACTOR PO at O,{ /7 7 S S
CITYA ZIP FAX
azy
WA ST ONTRACTOR'S LICENSE# EXPIRATION DATE FEDERAL WAY BUSINESS LICENSE#
7TZ-4 34-1J-C- ay/o/ //
NAME L7' //�VV7lC/— PHONE
APPLICANT MAILING ADD5a C
E-MAIL
CITY STATE ZIP FAX
PROJECT CONTACTPHONE
cy
(The individual to receive and NA11IN c.k ,D,,- �"� " ' 6"/ 3 i ((/ 73
respond to all correspondence MAILING ADDRESS E-MAIL
concerning this application) _
CITY 1' l/ C/tom! `, STATE ZIP FAX 1
ALTERNATE CONTACT NAME' : PHONE E-MAIL •
•
PROJECT FINANCING NAME
OWNER-FINANCED
Required value of$5.000 or more
(RCW 19 27 095) MAILING ADD• ,a,CITY,S ,ZIP
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.
/ U
SIGNATURE: A DATE 9 _ Z
PRINT NAME: /// / G C� Dell ‘''''ny`"' � £
Bulletin#100—April 14,2010 Page 1 of 3 k:\1-Iandouts\Permit Application