11-100716 l ( — ( OO / (0
F OF , PERMIT
Federal Way MF CO ME PL DE EN
COMMUA7TY DEVELOPMENT SERVICES A P P L I CAT I O N R E C E i v E D
253-835-2607•FAX 253-835-2609 4P
www atyoffederatway corn
FEB 22 j /
�OSITE ADDRESS SUITS UNIT krep
070/0 s . 3 1/1-/ 6-rg, .62 !CITY OF FEDERAL WAY- z
DS
PROJECT VALUATION ZONING ASSESSOR'S TAX/PARCEL#
$ o , / L4 Z6, 933 O __ (" coo
TYPE OF PERMIT ❑BUILDING 0 PLUMBING 0 MECHANICAL
0 DEMOLITION 0 ENGINEERING X'FIRE PREVENTION
NAME OF PROJECT
(Tenant Name/Homeowner Last Name) CDMOit) /q 2 7A Ail Ai
1111b
/77OA-)
A D b SF 2' '-L.et. PILO-ft c-T 1v."..) -r tI, .0 ..)e(A) .ice-kVA fu'NC
PROJECT DESCRIPTION
Detailed description of work to 1 IJ 6 k,STI"..)Cc S('2 i A.)14 t !;e (;n Xu ;L P!/VCr
be included on this permit only
NAME ,,//��'' PRIMARY PHONE
PROPERTY OWNER Tie, CHi412Le S gEmoA)� 263` 710 - 6000
MAILING 4ADPl AVE 6. E-MAIL
E.
CITY�L,�Ilr ST E ZIP
ei
NAME ,/'"/I/ 1 ec- sU 5701AS PHONE
- 1zee - 1YOO
MAILING ADDRESS L/ 1 ) L►� E-MAIL /J /�
CONTRACTOR ( ( 0(p ` 5-z1 " C (jam ' I (}�h€sm(1TK f rel
CIT I 6-0- 0•'1 MX ZIP 8 q ay FAX Zt/S,3-eq , -/ Z�(,.., ,
WA STATE CONTRACTOR'S LICENSE k EXPIRATION DATE FEDERAL WAY BUSINESS LICENSE#
.6444 IT1-4F5134OT I I 7 z 17- 101-g7-0000$s--oo -I3L
NAME PHONE
dame as eLlaot/C___
APPLICANT MAILING ADDRESS E-MAIL
CITY STATE ZIP FAX
PROJECT CONTACT NAME -red q Gteev1 PHONE
(The individual to receive and
respond to all correspondence MAILING ADDRESS ��� E-MAIL
concerning this application) a I1L -
CITY STATE ZIP FAX
ALTERNATF C9pN� NAME: PHONE E-MAIL
AI K
t kI Vey it e.► "- Z530-11--2.6(0S- vi vef n e.Ke_s_4u.c- -,gr ,
PROJECT FINANCING
NAME Celli.-
.......--- 0 OWNER-FINANCED
a)1 C-
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.
:LiSIGNATURE: DATE 2-- j tit- I
PRINT NAME: 7 Eb a v ET NI
Bulletin#100-.April 14,2010 Page 1 of 3 k\Handouts\Permit Application