19-105431 RECEIVED
NOV 2019 PERMIT APPLICATION
CITY OF � 1 2.rof
Federal Way CITY OF FEDERAL WAY PERMIT CENTER+33325 8th Avenue South+Federal Way,WA 98003-6325
COMMUNITY DEVELOPMENT,/ 253-835-2607+FAX 253-835-2609+permitcenterAcityoffederalway.com
PERMIT NUMBER i_9- L 0 _5 /Z FEy� L _ TARGET DATE (....... ''''''..".."............)
SITE ADDRESS SUITE/UNIT#
PR JEC 0 ` 9 N SI
3 S 1 c -f I
O ZONING ASSESSOR' TAX/PARCEL#
TYPE OF PERMIT 0 BUILDING 0 PLUMBING 0 MECHANICAL 0 DEMOLITION 0 ENGINEERING RE PREVENTION
NAME OF PROJECT 7z7/ 3q8 7(i-' -
PROJECT DESCRIPTION
Detailed description of work to / r125-
jr2 - //
� 644 . �;:ti Aix- rz 3
be included on this permit only J
N ...Oft PRIMARY PHONE
PROPERTY OWNER ijt AS /AI �I�� 163.' -3b3S
MAILING ADDRESS +L. E-MAIL
laiplD 4$ /4y&
c le11031
N ,s .n•� __l_C . 3NE-,692-57:20 fol,
MAILING ADDRESS ` MAID` '_�/
CONTRACTOR 11 135 ✓� /294k 6: £0k e,4c"s� `
C_� t F@ STATE� 12ZIP FAX
AJv YID I Vz /2 /�I EXPIRATION�� FEDERAL WAY BUSINESS LICENSE K
NITr7r 3 '1S, .1�tiG to/17/A/ .0- !f- 1Z$y
APPLICANT MAILING ADDRESS E-MAIL 9N► ST `(� 7124,2.... FAX
NAME % f PRIMARY PHONE
PROJECT CONTACT C ,►[�eww~`/‘
(The individual to receive and MAILING ADDRESS E-MAIL
respond to all correspondence
concerning this application) CITYATE ZIP FAX
NAME
PROJECT FINANCING ❑ 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 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 true and correct.I certify 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
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 • part o this application.
SIGNATURE: ,;LJ __ r/ DATE i/ �2'—l
PRINT NAME: CD".J 11y t1&-
Bulletin#100–January 29,2016 Page 1 of 2 k:\Handouts\Permit Application