10-105275 11111 A _ / 051-15
„.. A PERMIT SF MF CO ME PL DE EN m
Federal Way
COMMUNI7YDEVELOPME7SERVICE \/gr
PLICATION
253-895-2807•F ,• T
SITE ADDRESS_ 'DEC 1 el 2010 SUITE/UNIT#
Zo 11) S C - �,
PR A l t)Li ����� ASSESSOR'S TAX/PARCEL S
$ 3�V'`'v CDS oil* -
TYPE OF PERMIT 0 BUILDING 0 PLUMBING 0 MECHANICAL
0 DEMOLITION 0 ENGINEERING ICE FIRE PREVENTION
NAME OF PROJECT 1 t7 .
(Tenant Name/Homeowner Last Name) O�'WCS 1 �ESTaviZ4 iT5
PROJECT DESCRIPTION tAT ``TIO.4 oar it v f ai tiuT sea.t.Alo-c-¢ �s v1J eg. a
Detailed description of Mork to pI'W 1111 ,22_,A...l I d
be included on this permit only
NAME 7tHIARY PHONE
PROPERTY OWNER -am) -rpt.k ah.i Ciao 1-11- 9 y I L
MAILING 111011 ADDRESSen PA 4E SkiITE I lc IgAD'(11tfzso.i @ EAiFlU,ik•c'J7^.
CITY STATE ZIPWA 51/00d
NAME
E
1402 i t-1 s-r 'Fi R& Sgs-i vis 'IV&i 772-1 Co_
MAILING ADDRESS E-MAIL
CONTRACTOR •'3 1S S. 111¢-T0 ST SV 1 TE IIS' Arm(e #4140itesolass taw,
CITYSTATE1�31t.A A 9fI I,y Ft. ) -III- 1 so LI
WA S ATE CONTRACTOR'S LICENSE S EXPIRATION DATE FEDERAL WAY BUSINESS LICENSE S
c z t=�S91/fCA /2/ 31 2ol0 I0- lot Iii- oo-( L
NAME
d0 Y1� I ��✓l/1 V I '
PHONE
APPLICANT MAILING ADDRESS E-MAIL
CITY STATE ZIP FAX
PROJECT CONTACT A PWONE
(The indiU{dunl to receive and
3,t+Ro,4 710`i TER (2012) 7-4 1- 2242-
respond to all correspondence MAILING ADDRESS E-MAIL
concerning this application) 331 S S. ill l6 -1 ST. sV11 Te US- IOvrtieliMr1 OWSTE ti•1 atn.
CTTY ATE
'NKWtLa lM4 . ZIP 4Yt1.Y (20FAZ to -7-72--1 sr)4
ALTERNATE CONTACT NAME: PHONE E-MAIL
aeoptFE2- AA14L ) -rrm"isbt- 3AAALe1.1144FltE ..1S1r •cnr-
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 lows 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: 1" J DATE 121 I i I1-1.9 t t>
PRINT NAME: .4.4.o.1 ?e7-1-TE-ft.
Bulletin#100-April 14,2010 Page 1 of 3 k:\Handouts\Permit Application