19-105695 ` RECEIVED
PERMIT APPLICATION
CITY OF DEC 0 3 2019
PERMIT CENTER+ 33325 8th Avenue South + Federal Way,WA 98003-6325
Federal Way 253-835-2607 + FAX 253-835-2609 +permitcenter@cityoffederalway.com
COMMUNITY OF DEVELOPMENT AL •
PERMIT NUMBER /9
_ / O `"'� 6 9 5 _ r P
O5 v FP .
DATE
SITE ADDRESSSUITE/UNIT#
15, ( S uLOA4 9 o
PROJECTVALUATION ZONING �A ASSESSOR'S TALC/BARGEE#
$ kitS � _
TYPE OF PERMIT ❑ BUILDING ❑ PLUMBING D MECHANICAL ❑ DEMOLITION ❑ ENGINEERING ikEIRE PREVENTION
NAME OF PROJECT 1 k" I o k) l J L.1
PROJECT DESCRIPTION '
't 4
Detailed descnption of work toC-i 6"'t4(A'✓LAA„ ! v ' e vf,W F.„_.-✓L+.
be included on this permit only
NAME PRIMARY PHONE
-1-. -(. O 2 i,-J -
PROPERTY OWNERL `�DRESS c. 3 i t V..'
E-MAIL
CITY I
LA)
STATE ZIP1:; go
0 3
NAME PHONE
Peri L -Pe -R- _ /1 i&hi f . 200-••.t eS---?SI Z
MAILING ADDRESS E-MAIL
CONTRACTOR .2.:30-Z.,1,-. (SS I~ ONA.l
CI STATE ZFARS • AAO• -i5 �in. Lvu
/(/ TCO �TAI ��RACTOIEXPIRATION DATE FEDERAL
RAL WAY BUSINESS LICENSE#
- � �� 4 ���92NAME
PRIMARY PHONE
(VI pct,'-+ t c11:44".' Z53- ttsic, 1330
APPLICANT MAILING ADDRESS E-MAIL
(a3Z-3 a-( v�OUNAA-� -ktri-40 in 4 ' nni s+-*}*k@ 90-.evi,c,0, .
CI STAT ZIP FAX
NAME PRIMARY PHONE
PROJECT CONTACT ett C�/\•O P-1 S 1 "' .
(The individual to receive and MAILING ADDRESS
E-MAIL
respond to all correspondence ( 3Z 3 ��I3lr i hdl / teli�/�-e4
concerning this application) C STATE ZIP FAX
PROJECT FINANCING NAME ❑ 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 Iaws.
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 o the-reliance-of-the.....ity, including its officers and employees, upon the accuracy of the
information supplied to the city as • •art of this application.
SIGNATURE: �� DATE 45 C/) ( 9
PRINT NAME: < t.,& '' A e, t
Bulletin#100—January 29,2016 Page 1 of 2 k:\Handouts\Permit Application