19-105786 PERMIT APPLICATION
CITY OF RECEIVED
Federal Way PERMIT CENTER+33325 8th Avenue South + Federal Way,WA 98003-6325
253-835-2607 + FAX 253-835-2609 + rrnitcente ,r,ciiyo`federaiway.corn
DEC 10 2019
Lit /,,,CITY QF F ' APERMIT NUMBER _ /WtMUr P"" L,1G(t' _ j`ARGET DATE Ia
SITE ADDRESS-5)0(0 C/42 j"%L I A(, SUITE/UNIT#
fc1F'edel'ret4 \,00-y W °16023
PROJECT VALUATION ZONING ASSESSOR'S TAX/PARCEL#
$ • 410-' _0 3 7- 0 - (31 Q 'B I
TYPE OF PERMIT ❑ BUILDING ❑ PLUMBING ❑ MECHANICAL ❑ DEMOLITION ❑ ENGINEERING FIRE PREVENTION
NAME OF PROJECT Y w\oYbv Lake. V;11 r'c ate,
PROJECT DESCRIPTION kre kw() (2, r\t .) �O& i,atcA OV' vc.\vec ava d }aw�c✓
Detailed description of work to SW\k"Clout.S C1n 42466 -1", (o" ei✓G SevI'v►k(GV" iJv O AlYW,/ld av fof ly.
be included on this permit only
NAMEPRIMARY PHONE
PROPERTY OWNER MAILING
` NI�Ov N.�� v i��0.� L1-G
ADDRESS E-MAIL
$34, sv) 3\2,P' c
CITY FCCkt�� STATEZIP �°V2)02.1NAME �"] - PHONE
Ve"igkt- FCrc Pro ec,;-to a 3(00•15(0•'2)t0 G"
MAILING ADDRESS
E-MAIL
CONTRACTOR LJ k%wo f 1,14. Ov Sl/J v1(1x,.-II.0 Q ft, tlt.+��
CITY STATE ZIP FAX
Tuvwwo-ktse Wpt 9$SIZ 344•'}$(x• $IZZ.
WA STATE CONTRACTOR'S LICENSE# EXPIRATION DATE FEDERAL WAY BUSINESS LICENSE#
kNA 1}FPOLV-1Lk �Z. / 3\ / t3-10524b-0o-SL
NAME PRIMARY PHONE
IMo. CM`r CO 148(o 5(000
APPLICANT MAILING ADDRESS E-MAIL
C1-102. Lathrop lnd. Dv: .5,.) �nnu�-I�c,Q1�n;sti.tF;v�.�e1'
CITY STATE ZIP FAX
�vvva wtict i W IPt QI2SIZ $(00•I8(.•$1-2Z
NAME PRIMARY PHONE
PROJECT CONTACT Mp,,,,it. �n (( 36b•let°• '' (o
(The individual to receive and MAILING ADDRESS E-MAIL
respond to all correspondence q*OZ LAM,roe lwd- Dr. 5vi orw.-1(...c.Q. 1a-f(NC. Att
concerning this application) CITY�v ���✓ STATE ZIPFAX
R�t�
W 3(00 � Ci f5-41,T,
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 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: '•AA AA -- DATE VZ'9• a
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PRINT NAME: V k. CAw,kie-t
Bulletin#100—January 29,2016 Page 1 of 2 k:AHandouts\Permit Application