19-104638 RECEIVED
„„„,...4.. SEP 26 2019 PERMIT APPLICATION
CITY OF CITY OF FEDERAL WAY
Federal Way COMMUNITY DEVELOPMENT PERam.Mane+33325 8m Avenue South+Federal Way,WA 98003-6325
253-835-2607+FAX 253-835-2609+peuniiceni.er<<i.citvof1ederalcay.com
PERNUMBER 1 1 _ ) 011 (
MIT q _ r D- TARGET DATE
let
SITE ADDRESS - . SUITE/UNIT T
X3,0 0 q-ilvi tts(A)
PROJECT VALUATION tOlfntCi ASSESSOR'S TAX/PARCEL 11 9 I if
1P _ 0 ,_ 9�A
2.500 °-2 `j1/ g _ „,IT I/_11 - - —
TYPE OF PERMIT 0 BUILDING 0 PLUMBING 0 MECHANICAL 0 DEMOLITION 0 ENGINEERING (FIRE PREVENTION
NAME OF PROJECT 177 trio•- . 2, /I ssis e," GE v/1- , 4i .'
PROJECT DESCRIPTION
47 M-ff #-ni iC/ A, M K1 Tom- Ler/ h1' Sit : p.
Detailed description of uaork to � 7
be included on this permit only
NAS E , PRIMARY PRONE
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PROPERTY OWNER SWISIMn am+eaan _ S•MAII.
cTT ,., STATE �
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�a�IJ�LaPHONE
.S� C-1),"447‘4�04 S
EA
qG2CONTRACTOR CITY siA'ls FAX ,. ,�...._ - _ I CO
WA STATE CONTRACTOR'S LICENSE• ELr/RATIO11 DATE FEDERAL WAY EUSINWSs LUClsifBE a
/ /
NAME
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a1 & ,tj 1 004,-( 41aids F 77 o E .sus 20
APPLICANT -- z) jt) ( S f4,A Swed &sic j..Gorst
all STATE LW FAFAXe W4 7,/e)
t
NAME
/y�}y�J/G PRIMARY MONS
PROJECT CONTACT _. '')/1-41e-
� 1-••
(The individual to receive andluAnal°ADDRESS E-MAIL
respond to all correspondence
concerning this application) CITY STATE LIP FAX
NAME 0 OWNER-FINANCED
PROJECT FINANCflIG
When value is$5,000 or more MAILING AsaixsR,CITY,ETATS,LW PHONE
fRCW 19.27.095)
I certify under penalty of perjury y that I am the property owner or authorised agent of the property owner.I certify that to the best
of my knowledge,the information submitted in support of this permit application is tree and correct.I c rtlf jt that I will comply with
all applicable City of Federal Way regulations pertaining to the work authorised by the issuance of a permit.I understand that the
iesuann of this permit does not remove the owner's responsibility for compliance with local, stale, or federal laws regulating
construction or snehmunentnt taws.
/further agree to hold harmless the City of F.aderal Way as to any claim(including costs,expenses,and attorneys'fe In
the investigation and defense of such claim),which may be made by any person,including the unds►signed, thed against the
of the
but only where such claim t W the reliance of the city, iaeledtng its officers and employees, upon
information supplied to .•• a part of this application.
�..w[• ' /3 /4P
SIGNATURE: . -� DATE
PRINT NAME: A4 ,. r- ie./7
Bulletin#100—January 29,2016 Page 1 of 2 k:\Handouts\Permit Application