17-100134 ,,,„,..,4_, Ka*MD PERMI PAPPLICATION
CITY OF
Federal WayJAN 1 0 20 17 PERMIT CENTER+33325 8th Avenue South + Federal Way,WA 98003-6325
253-835-2607 + FAX 253-835-2609 +permitcenter@cityoffederalway.com
CITY QF FEpeaugglif
PERMIT NUMBER / 7 _ / 7 3 Si - C 0 TARGET DATE
SITE ADDRESS ! SUITE/UNIT#
'3c)Lp 3 pG,i' J i'c. � 5
PROJECT ALUATION ZONING ASSESSOR'S TAX/PARCEL#
TYPE OF PERMIT UILDING 0 PLUMBING 0 MECHANICAL 0 DEMOLITION 0 ENGINEERING 0 FIRE PREVENTION
NAME OF PROJECT "/ TA e 1441 r2 join-)—_o(nr
PROJECT DESCRIPTIONdi
b a In.La I P-12- `.11,- --
Detailed description of work to
be included on this permit only
-- - -- - N �5i// rh11.4"
` PRIMARY PHONEPROPERTY OWNER MAILING ADDRESS E-MAIL
--)'\--, b....4_,...e....c.
CITY V STATE ZIP
-- --- - NAME .. —.-- - PHONE
MAILING ADDRESS E-MAIL
CONTRACTOR
CITY STATE ZIP FAX
ATE CONTRACTOR'S LICENSE N EXPIRATION DATE FEDERAL WAY BUSINESS LICENSE#
__ _ _ / / X6-1/7-35 2
_
NE
APPLICANT MAILING ADDRESS C•I► E-MAIL
9, 1-i ]ViC.41,2Sait) 64- Migok MGtikin2seleCandjx4.,i,
CITYY .�+� STATE ZIP FAX
,..ICr' I )C wit!}- -I QO¢/ ° C
dry'
NAME PRIMARY PHONE - --- -l
PROJECT CONTACT Maw k J c 4,1 it.)
(The individual to receive and MAILING ADDRESS E-MAIL
respond to all correspondence
concerning this application) CITY STATE ZIP FAX
NAME -- - -- -PROJECT FINANCING 0 OWNER-FINANCED
When value is$5,000 or more MAILING ADDRESS,CITY,STAT �! 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 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: /'ILDATE I/10 11-7
PRINT NAME: I� 0/47L-
NIVICI.114
Bulletin#100—January 29,2016 Page 1 of 2 k:\Handouts\Permit Application