19-104655 _._ ..4.,. RECEIVED PERMIT APPLICATION
CITY OF
Federal Way ) 7 2019 PERMIT CENTER+33325 8th Avenue South+Federal Way,WA 98003-6325
SEP G253-835-2607 + FAX 253-835-2609 +permitcenter@cityoffederalway.com
GIP(OF FEDERAL WAY
C' " .,iUh`lY L PM � Fp PERMIT NUMBER _l / ((�� TARGET DATE
SITE ADDRESS SUITE/UNIT N
3q4? lc•- ki- . S_
PROJECT VALUATION ZONING ASSESSOR'S TAX/PARCEL M
$ 52960 — (J` l 0 _ q 1 / 0
TYPE OF PERMIT 0 BUILDING 0 PLUMBING 0 MECHANICAL 0 DEMOLITION 0 ENGINEERING a RE PREVENTION
NAME OF PROJECT ?/ ilk-, k---Ac k_t: G S
lrLt"A-P , ' sus-1,-c. — E n_E- pA. l 4. Ad. ....t rC,Ar�c ( 4,t
PROJECT DESCRIPTION � n II 1
Detailed description of work to (.A' -c C.
nk-t--LJ— Brei. C)3-c ?,/t.( a 6f✓Cu C
be included on this permit only Ieer j i'-� ��;r--,C_7 H "-
- - NAME - - PRIMARY PHONE _.
p..0 se_
PROPERTY OWNER MAILING ADDRESS E-MAIL
CITY STATE ZIP
NAME
t7 It 1z ✓ho,Nt f...rer Li L Lc.... Pz7 3 X6 7 SLaG
MAILING ADDRESS E-MAIL _
CONTRACTOR pU bay- /vo k Fries r-g'Alit•ee.^,
CITY STATE ZIP FAX
S✓,.I.^ N. 141A 9 $3JE0 —
WA STATE CONTRACTOR'S LICENSE# EXPIRATION DATE FEDERAL WAY BUSINESS LICENSE X
DrhdlJQ/v. Scy-7 (L- S/Zfi /2•0 , ZO-f-/DDS29-6d-/3L
NAMEPRIMARY PHONE
`Fa-A Jk_ bj, &�e5l.-t_ 253 - zz i=79 r c
APPLICANT MAILING ADDRESS *jun
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CITY STATE ZIP FAX
,,,r,N`e.A WA 7 )e3
NAME PRIMARY PHONE
PROJECT CONTACT S -
(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,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.
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SIGNATURE: DATE 7M
PRINT NAME: ri-N k- P, 4,9-1,
Bulletin#100—January 29,2016 Page 1 of 2 k:\Handouts\Permit Application