17-105661 RECEIVED
,„A„,_. Nov 2 2 2017 PERMIT APPLICATION
CITY OF
017 'OF FEpE PERMIT CENTER+33325 8th Avenue South+Federal Way,WA 98003-6325
Federal ay OpMMUN17Y D WAS( 253-835-2607+FAX 253-835-2609+permitcenterid,cityoffederalway.com
EVELOPMEp
PERMIT NUMBER 1 _ /_0 512 (e I _ 5 ( `
/ SlYYY/// TARGET DATE
SITE ADDRESS SUITE/UNIT S
Z93 A/ Y41`/IW kil
PROJECT VALUATION ZONING ASSESSOR'S TAX/PARCEL# ii
TYPE OF PERMIT )(BUILDING 0 PLUMBING 0 MECHANICAL 0 DEMOLITION 0 ENGINEERING 0 FIRE PREVENTION
NAME OF PROJECT dead-5
PROJECT DESCRIPTION 2e Ace ( AgeS' k � *eel, 434,...21-1
4�~ (� Al7
Detailed description of work to a X Eici: 4'U es,rfai
Q of /3QPi?�e 14JA
be included on this permit only
NAME � PRIMARY PHONE
IO C kw-- do//'VA 3Z-3- FS z3 -06,0 Z---
PROPERTY OWNER MAILINQ ADDRESS E-MAIL, //
29131/ y�k- A(la s w /-/ A
CI,Q1/ f4� u�ay STATE ZIP
3
NAME A(14 ASatM�# MIR Wil z- h PHONE - .'t g• '7
MAILING ADDRESS E-MAIL
CONTRACTOR 'Po ax 3 92-4 O
z53-51.3 -0ZP1
WA_St�L 'TE CONTRACTOR'S
137 / /77 /19 z ov-/oL%as-SSL,
N i.e.°�/'t �/N 2�7 PRIMARY PHONE`�g 4- If/e71
MAILING DRESS E-MAIL
APPLICANT
o ,ate ,3pZ2 � 4-.e4L 400,5dX'V iO4
CITYSTATE Z FAX
/ kei i WAg$‘194 25-3-5g5 sOz-97
NAME PRIMARY PHONE
PROJECT CONTACT ,,S
(The individual to receive and MAILING ADDRESS S Foe Q (1/ E-MAIL
respond to all correspondence �W'�' I
concerning this application) CITY STATE ZIP FAX
NAME
PROJECT FINANCING 0 OWNER-FINANCED
L 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 ci as a part of this application. 7/-/
SIGNATURE: ,
' ', - DATE i 7
PRINT NAME: _ -O
Bulletin#100-January 29,2016 Page 1 of 2 k:\Handouts\Permit Application