19-104749 RECEWED_ R. 1 N ,K L. R,
CITY OF 4A ERMIT APPLICATION
Federal Way OCT 0 2 2019
CITY OF FEDERAL WAY
MMUNIY DOPERMIT NUMBER Iqco
_ _ F-10
TARGET DATE
SITE ADDRESS
SUITE/UNIT#
2o S 3 32-011 St 2Ie/R
PROJECT VALUATION ZONING ASSESSOR'S TAX/PARCEL#
$ 1081/. 75 -� 7 g 2 o _ o S 3 5
TYPE OF PERMIT ❑ BUILDING ❑ PLUMBING ❑ MECHANICAL ❑ DEMOLITION 0 ENGINEERING eIRE PREVENTION
NAME OF PROJECT eoldnitiri
f �11,iJ'e m`es 24e1
ftda k ed y i " efs .(J A`fQ 4127,7 /4/01/
PROJECT DESCRIPTION
Detailed description of work to fre/0e1I/
be included on this permit only
NAME PRIMARY PHONE
PROPERTY OWNER DM v e-kl"'rE V tgGS RA) CeTF2 GC
MAILING ADDRESS V E-MAIL
CITY STATE ZIP
NAME PHONE
-rnitity eme frotf'7rh lac. 763-X72-7Z2Z
MAILING ADDRESS
73
CONTRACTOR 4✓ S 20bm 626 Lvpel�/rnov�
CITY STATE ZIP FAX
Kll,{- Gtr 98CY z
WA STATE CONTRACTOR'S LICENSE# EXPIRATION DATE FEDERAL WAY BUSINESS LICENSE#
, > C iei."21%D72 CCS / 3/ / 11 c910-00-10/(46 -6o-&tC.
N E 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
NAME
PROJECT FINANCING 0 OWNER-FINANCED
Required value of$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 city as a part of this application.
JAW .401.
SIGNATURE: Oa/
� DATE `
PRINT NAME: /Aa !r/7 e ! e l S0'?
Bulletin#100-January 1,2013 Page 1 of 3 k:\Handouts\Permit Application