19-105482 RECEIVED
CITY OF �./ NOV 14 2019
PERMIT APPLICATION
Federal WayDDEVELOPMENT
PERMIT CENTER+33325 8th Avenue South +Federal Way,WA 98003-6325
MMUNfTY D 253-835-2607 + FAX 253-835-2609 +permitcenter®cityoffederalway.com
COMMUNITY
PERMIT NUMBER ) 9 _ L o5 Li Q !i— . P ?
TARGET DATE
SITE ADDRESS
/ / M 6.i._ SUITE/UNIT#
6, s- 3 lc i/" Y�
PROJ t 'ALUATION ZONING ASSESSOR'S TAX/PARCEL#
$ 0 °p _
S"'` --F PERMIT 0 BUILDING 0 PLUMBING 0 MECHANICAL 0 DEMOLITION 0 ENGINEERING ❑ FIRE PREVENTION
NAME OF PROJECT 1 (i rror 0,kG Cj ltwl erl :3 Sa 00 L
PROJECT DESCRIPTION AiLl�d'� aJ —ray)
hyla/rq4-or
Detailed description of work to pYb Dart L ! 1( J).$) )ter
be included on this permit only
NAME
ra ' wet.) P/blec. &CA ' PRIMARY PHONE
PROPERTY OWNER MAILING ADD S Na E-MAIL
12.E ./ /� g32 met'
CITY el h\ %,(VIA u� \%A', �P 1 goo 3
NAME mRNA CsmeeWvC.'‘‘avy ( t3eC) t5L .S 88
CONTRACTOR MAILING2823
8 2 3 �ci Avg 'w EMAIL
CITY . 1% A W i 4VP' ZIP FAX
$S( - FA%
WA STATE CONTRACTOR'S LICENSE# EXPIRATION DATE FEDERAL WAY BUSINESS LICENSE#
/ /
NAME Ali
lel A-1 .„,4/ (: PRIMARY PHO
a-c3)2-b9 - 8336
APPLICANT MAILING AD tFi$a2 e. sw
tarn ed edit Q�4 Cc.
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CITY T�,�n old L_�. STATE ZIP FAX
/
NAME ' r 1 ( PRIMARY PHONE
PROJECT CONTACT 3 ail Ari!I Cr�],/��,`1
(The individual to receive and MAILING ADDRESS E-MAIL
respond to all correspondence
concerning this application) CITY STATE 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 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 lance of the city, including its officers and employees, upon the accuracy of the
information supplied to the city as a part s plication.
v
SIGNATURE: DATE 1 I h3/2(:)/
PRINT NAME: an d k w el i*II
Bulletin#100—January 29,2016 Page 1 of 2 k:\Handouts\Permit Application