15-105357 B..CEIVED
CITY OF A
OCT 20 2015 PERMIT PPLICATION
Federal Way
CITY OF FEDERAL WAY
CDSFIR E
PERMIT NUMBER $ 5 _ J 6 5 s 1 - f IQ /P-
TARGET
1 I DATE
SITE ADDRESS SUITE/UNIT#
2 \31 5 33 Co }k Skr e Q n I A
PROJECT VALUATION ZONING ASSESSOR'S TAX/PARCEL#
x , 000 4g73zk D (�
R Mr` T.
TYPE OF PERMIT 0 BUILDING 0 PLUMBING 0 MECHANICAL 0 DEMOLITION 0 ENGINEERING �Q FIRE PREVENTION
NAME OF PROJECT ei
k., lig_.;
PROJECT DESCRIPTION
(Lek or a 3ri
5 n tc l e r (- acs a n A a d cl
Detailed description of work to 4 r he R I-i-e. A , C` kV..1. ; -C Irn t'c
be included on this permit only
NAMEPRIMARY PRONE
PROPERTY OWNER \ \ )e f k so (1‹, L L,C, , $y7 g J`j -01-9 z
MAILING ADORES _ E-MAIL
RoZo)( &ldO
PR t M\0 0 p 0 I i s 8a\i0 �5 5 uNt
PHONE
Crowr\ ..re. Pc' 4--ec +( 0A k25y1f174,G `t
MAW°ADDRESS E-MAIL
CONTRACTOR 0 VC:i )( (-Z 11--
� iCA4CfO�nce.:151►?
CITY STATE FAX
OA tl crag. V- ,. at On tZ
S K Si /qq1 S
WA STATE CONTRACTOR'S LICENSE# EXPIRATION DATE FEDERAL WAY BUSINESS LICENSE#
C(LD- U ' oyIA, LL 10 X25 /lc, ia - 'u-(01 1i- oo-pc.
NAME ,„.,- PRIMARY PHONE
essica oby,c\son L\zsyii '16c1
APPLICANT MAILING ADDRESS
Po r�6psi( k21►3 ,e5.;c.II@CfOL- ICe.00rn
CITY t' \\ N ee,V- STATE ZIP FFAXLk-ZS-431' Zob Z g( j 1
NAME _ PRIMARY PHONE
PROJECT CONTACT 1 l ZQ(e i ( Se''' t o1 nSo,j '-(Z 5 LQ`b( 71.41
(The individual to receive and IMG,A/DDDRESS E-MAIL
respond to all correspondence Po tx !2 I(3 , 2s5 I L 4 ex_co-. \ f•C b r11
concerning this application) CITY STATE ZIP
vv ( Db S
-,ll L( v i..) 1tiYo 157— W25 D
PROJECT FINANCING NAME \ I A 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
issall licable City of Federal Way regulations pertaining to the work authorized by the issuance of a permit. I understand that the
ante of this permit does not remove the owner's responsibility for compliance with local, state, or federal laws regulating
co ruction 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 ofthisapplication.
SIGNATURE: #I4d41.-(A " f/6/2 >off-•
DATE 'b/(9//f
PRINT NAME: le-5c Q(SSLC �O J(n)O,1
Bulletin#100—January 1,2013 Page 1 of 3 k:\I-Iandouts\Permit Application