18-104840 RECEIVED
PERMIT APPLICATION
CITY OF �.� OCT 15 2018
Federal Way
PERMIT CENTER+33325 8th Avenue South+ Federal Way,WA 98003-6325
CITY of FEDERAL WAY 253-835-2607 + FAX 253-835-2609 +permitcenter@cityoffederalway.com
COMMUNI-TY DEVELOPMENT
PERMIT NUMBER ' _ g 6� `/ - 0 to TARGET DATE I
SITE ADDRESS SUITE/UNIT#
t O 0 A 3 \tf c3 o? S\-
PROJECT VALUATION ZONING ASSESSOR'S TAX/PARCEL#
$ 3{ pow 1 '-I "7 O _ p 2_ 9' U
TYPE OF PERMIT ❑ BUILDING ❑ PLUMBING ii,MECHANICAL 0 DEMOLITION 0 ENGINEERING 0 FIRE PREVENTION
NAME OF PROJECT `
‘-kPROJECT DESCRIPTION evrticv 6 �C\p`C C I)—J v r&`C
Detailed description of work to Y
be included on this permit only
NAME rPRIMARY PHONE
eV\.'ilt,C t IOC ke \ Z°\t", 1 let_ .C1c1
PROPERTY OWNER G l � V
LING ADDRES c'„l ('1 E-MAIL
(rVl 1 � Oy l\�
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-- - CITY \ 7/Er.,..
0xZIP,/ O' C „--c-lVeV4NAME"-"-----n-‘
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MAILING ADDRESS
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CONTRACTOR Sv �0�' v��� E-MAIL
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CITY p 4 \ c. ZIPQ y u+ y FAX
WA STI�TE_CONTRACTOR'S I�SE M� �� EXPO/ TION DATE FEDERAL WAY BUSINESS LICENSE#
NAME rr�` 11.•-- l� ` c. PRIMARY PHONE
3 a t
APPLICANT- MAILING ADDRESS I.
e" S \ ic: e �• c_4' E-MAIL
r
CITY 14 4 h S L�,.,C.- STATIC ZIP I 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
•
NAME - --
PROJECT FINANCING ❑ 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 arty 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 suppliedcity as a part of this lication.
SIGNATURE: c.
4...7
. DATE S” o��a ��'
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PRINT NAME: - V'C 1 ` • 0 \r'.
I
Bulletin#100-January 29,2016 Page 1 of 2 k:\Handouts\Permit Application