19-104402 RECEIVED
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SEP 1 3 2019 PERMIT APPLICATION
Ca/h.,' OF "
-Federal Way CITY OF FEDERAL WAY PERMIT CENTER+ 33325 8 'Avenue South + Federal Way, WA 98003-6325
253 835-2607 + FAX 2.53 835 2609 + pcirnitcenter",,,(...;hotWx€<thy:t\wom
GOMMUNfTY DEVELOPMENT
PERmrr NUMBER / IC) „_ / 0 C./ (7/ 0 a -
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TARGET DATE
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SITE ADDRESS 1 SUITE/I/NIT 0 1
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PROJECT VALUATION ZONING : ASSESSOR'S TZ/PARCEI.•
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1 1 TYPE OF PERMIT 0 3Lit,D771C, .1:1 PLUM a'1",', 0 MECEIANICAt 0 Dr.',101.:1-ON D E -JN? . _PIPE PRF.',EN-rt<P4
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NAME OF PROJECT -1-C`0,CI-1,,‘Ir2,qs 61.6 F-cott t 64 t,)a
PROJECT DESCRIPTION
Detailed description of work to 140.00_. ' ,* P ........,
be included on this perritit only
SAME PRIMARY PHONE
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PROPERTY OWNER MAILING ADDRESS E-MAIL
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CITY STATE ZIP
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NAME PHONE
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MAILING ADDRESS
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CONTRACTOR
i CITY ; STATE I ZIP FAX
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WA STAT CONTMCTOR'S LICENSE 0 EXPIRATION DATE FEDERAL WAY BUSINESS LICENSE
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NAME PHONEPRIMAR
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i MAILING ADDRESS E-MAIL
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APPLICANT -
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CITY ' STATE [ ZIP --- FAX
NAME PRIMARY PHONE
PROJECT CONTACT -6 a,......,_ a,..› a
(The nidwtdual to receive and MAILING ADDRESS E-MAIL
respond to all correspondence
concerning this application) CITY STATE ZIP FAX
PROJECT FINANCING
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When value is$5,000 or more MAILING ADDR S: CITY,STA,; ,ZIP PHONE
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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 th city as a part of this application.
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SIGNATURE: _,- „ ,doe „ DATE 7 /Z i ty
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PRINT NAME:
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Bulletin 4100 Janr.a 29.2016 l'iwc I 1,0 2 I,. llant,loxs l'erant Application