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16-105597
,► • PERMI'1•APPLICATION CITY OF Federal Way PERMIT CENTER+33325 8th Avenue South + Federal Way,WA 98003-6325 253-835-2607 + FAX 253-835-2609 +permiRfC ay.com • PERMIT NUMBER I (P 1 10 5-59 _ ' t NOV 2 3 2016 - TARGET DATE CITY OF FEDERAL WAY SITE ADDRESS lc7e a 3 SUITE(), g# 60) s \.) ST F Ifrc&( Cy(Ay tUA PROJECT VALUATION ZONING ASSESSOR'S TAX/PARCEL# 9Zc4- GiO _ n � �o TYPE OF PERMIT BUILDING 0 PLUMBING 0 MECHANICAL 0 DEMOLITION 0 ENGINEERING 0 FIRE PREVENTION NAME OF PROJECT / \� 4ZC) Cj�C) PROJECT DESCRIPTION l r e l e S d�d �}i o n Detailed description of work to be included on this permit only NAMEPRIMARY PHONE � S � g�o as-3-4/31— 6� 1� PROPERTY OWNER LING ADDRESS MAIL 6©a s w .3d SI- V1-$Fee ;Yiy SZ_Goro(t CITY STATE ZIP -ever c1L 1----)Uy 1J� of© a3 NAMECj Z. PHONE O MAILING ADDRESS E-MAIL CONTRACTOR CITY STATE ZIP FAX WA STATE CONTRACTOR'S LICENSE# EXPIRATION DATE FEDERAL WAY BUSINESS LICENSE# NAME CU 11 `�•\ PRIMARY PHONE APPLICANT MAILING ADDRESS E-MAIL CITY STATE ZIP FAX NAME PRIMARY PHONE PROJECT CONTACT (The individual to receive and MAILING ADDRESS E-MAIL respond to all correspondence concerning this application) CITY STATE ZIP FAX PROJECT FINANCING NAME 0 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 such claim),which may be made by any person,including the undersigned, and filed against the city, but only where su - • arises out of the reliance of the city, including its officers and employees, upon the accuracy of the information sup led to t c - •- a part of this application. //_d3-76 SIGNATU- : y/� DATE PRINT NAM . p r I (� S K K v e 0 Bulletin#100—January 29,2016 Page 1 of 2 k:\Handouts\Permit Application