19-105476 ..,,,,,,,.... _A. FilliVED PERMIT APPLICATION
CITY OF
Federa I Way Nov� 14 2019 PERMIT CENTER+33325 8th Avenue South+Federal Way,WA 98003-6325
253-835-2607+FAX 253-835-2609+permitcenter(dcitvoffederalway.com
Lf1Y OF FEDERAL WAY
coMMUNr1Y DEVELOPMENT
PERMIT NUMBERI ? .
7 /_
— 7_ TARGET DATE
SITE ADDRESS SUITE/UNIT#
33$\O \ueyec e,cw- Wil S Suo\z,\\0 Fes ta\ v I ,5 0
PROJECT VALUATION ZONING ASSESSOR'S TAX/PARCEL#
a,5va 1 \ SA_ 6 6 - o ."1 o
TYPE OF PERMIT ❑BUILDING 0 PLUMBING 0 MECHANICAL 0 DEMOLITION 0 ENGINEERING L�FIRE PREVENTION
NAME OF PROJECT .; ✓ cr.s\Isv
PROJECT DESCRIPTION
Ihs\a\\ c‘ce O i kl:CQ 1 c\e\gcc�ae el.Bloc
Detailed description of work to &V\GCS, �,\L ek.gt\e4 CACCx,:Occv( SOC �tle.sit� O S \e e _
be included on this permit only
.....it.... ..... FLSEp O C Tut.
NAME PRIMARY PHONE
PROPERTY OWNER MAILING�D� ' 'zkR\O\1tllexl'N' E-MAIL�S`t as,vtsL'�o
AIL
(01 1.% \\6\iN 0,0E 1cft- SI-,...0,C \coftoke..ccNGrriss 6,e4.26D inet- •aryl
CITY STATE ZIP
Nt:.C\ON\C a, A c\tt033
.(�1 [ �r� ^�
NAME PHONE
r.)\co \ G.�CA�s c�\ W3- 1�-
MAILING ADDRESS E-MAIL
CONTRACTOR 3a5 VpaShac qo t- plve. S 'cZ►q\ 1/44 `qgo e, %c•WVA
CITY STATE ZIP FAX
41flAk N Q`80-3a.
WA STATE CONTRACTOR'S LICENSE# EXPIRATION DATE FEDERAL WAY BUSINESS LICENSE#
MS k.)Eac'yw c° S ac
NAME PRIMARY PHONE
(DV -c\ \eC\f\e. l'OC. ).53-4101-VQc:t.
APPLICANT MAILING ADDRESS `\ �
EMAIL
Atit
CNA U•50•-i�`` a
`+STATEITY IZIP FAX
® *\Visi-k..reA
NAME PRIMARY PHONE
PROJECT CONTACT Zf\s-o,5 V.,(\pQ a%`'Ne ta,^\QHS
(The individual to receive and MAILING ADDRESS I E-MAIL
respond to all correspondence '5 ��4b\liv(`�p' ' k.)Q. \ NOSO, Cit.( 01)2,\gdf iC.-OCA
concerning this application) CITY STATE ZIP FAX
V\tiN\ WA
PROJECT FINANCING NAME 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.
SIGNATURE: DATE \\(\-(\4
PRINT NAME: •ACU T '5
Bulletin#100—January 29,2016 Page 1 of 2 k:\Handouts\Permit Application