17-102626 Zii f 21
` RECEIVED PERMIT APPLICATION
CITY of __� I O
Federal Way0 1 2017 PERMIT CENTER+33325 8th Avenue South + Federal Way,WA 98003-6325
JUN 253-835-2607 +FAX 253-835-2609 +permitcenter@cityoffederalway.com
PV1-7
,,'1"'M OF FEE RAL_ �!'i
PERMIT NUMBER I 1F� :L� -
OfTARGET DATE _ _
____ ___
/ ( 77
1
SITE ADDRESS
�1 SUITE/UNIT#
1. - S. LiA. Cair\f3(A.S. 1Jr Pk),,ii- 7
PROJECT VALUATION ZONING ASSESSOR'S TAX/PARCEL#
$ �a�x�, C ; 1 9 2 l G - 9 o I 7
TYPE OF PERMIT 0 BUILDING 0 PLUMBING 0 MECHANICAL 0 DEMOLITION 0 ENGINEERING 0 FIRE PREVENTION
NAME OF PROJECT
Aver,. l fhe e.s'eru4z
Ip.,- GrrholA icv e "r (.f So(,) - cinc) P p,-1 d,';- No Q-r-
PROJECT DESCRIPTION /n� t r 1
Detailed description of work to ISP G,Ce Ctn.] 1 i1�� `j' -f l'�erk,'ry' CEJ'( hP C�e(- ,
be included on this permit only7 ! / I i a.:/0 I ( f l .
�-h A �j 1l Iwo) I S N O oily Ii'-x--0...' P(/lr p ) eitc,/ el') to, ce,.?eater
✓, r
IAAkf11l neI.3 36 \'Y Li Si,'nc)ker /
NAME PRIMARY PHONE "N
Co�1 AM Ione, men FSU -011 -73 a
PROPERTY OWNER MAILING ADDRESS l` E-MAIL
3 JcjG f�(�I fp
1�t,,I'I2 Joe) Cly.,des-2 cc„40, • CC 0A
CITY IN ilerjd Ciii ATE z� J1113
NAME PHONE
(Grh ci, ROC: YN) SPl'V,'Ce,r 1V-319 --C'13 S
M/MILLING ADDRESS
/00OG /e,co/1,c, Way L :l 6-
S E-MAILo" Cc;p,
tc-
CONTRACTOR lSj��L\ � '(x�^/�/�/• (%rt✓•(��G':7�Gr�tt�hKJ(rV
CITY./ /()IN�� I'V�l ZIP i U - / / FAX
WA STATE LICENSE It EXPIRATION DATE FEDERAL WAY BUSINESS LICENSE M
NAME j , PRIMARY PHONE
a\ ; he)e 15 71- 7CC 1
APPLICANT � NG ADDRESS E-MAIL
Seirge C\s' CCr\f l-c,CtC r
CITYSTATE ZIP FAX
NAME PRIMARY PHONE -7
PROJECT CONTACT auR,.. LCA.ZDV aS-3-- 7�.z-,/�v!J
(The individual to receive and MAILING ADDRESS E-MAIL
respond to all correspondence SG�,e �� a n� e -
concerning this application) CITY STATE ZIP FAX
NAME
PROJECT FINANCING 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 such claim arises out of the reliance of the city, including its officers and employees, upon the accuracy of the
information supplied to the ty as a part of this application.
SIGNATURE: ,e,—<..... 14.'' DATE / 6117
PRINT NAME: D l LC%IChc c .,
Bulletin#100—January 29,2016 Page 1 of 2 k:\Handouts\Permit Application