19-104100 , r
RECEIVED PERMIT APPLICATION
. 441,4..S.... 9 PERMIT CENTER+33325 8th Avenue South+Federal Way,WA 98003-6325
CITY OF ' AUG 2 6 201 c_oA(I7 RAI( S -RT4 cermitcente oci offederalwa'.com
Federal Way CITY OF FEDERAL WAY
COMMUNITY DEVELOPMENT
L/ 100 _ 1."-- ? f°
TARGET DATE
Mawr NUMBERI - •
SUITE/UNIT
SITE ADDRESS
9/1( S w 3,2 11-
PROJECT VALUATION �/j�
ZONING ASSESSOR'S TAXIPARCNL#- �/ - IIJJ /�(= J
D
r lig
ERMIT ❑BUILDING 0 PLUMBING 0 MECHANICAL 0 DEMOLITION 0 ENGINEERING, FIRE PREVENTION
q'ypEOFP
/)/1oT6cr/o�
PROJECT DESCRIPTION
Detailed description of work to
be included on this permit only
-- — _
c ;/ o
NU '4- 6
PROPERTY OWNER MAILING ADDRESS 60
EMAIL
11111111111111111111111 STATE ZIP A
MAILING ADDRESS .1#4° €-) Q sO4F F Qi t:::-.�r�FAR
CONTRACTOR CITYr � A ATE ZIP ��375' 1 t/ EXPIRATION DAIS FEDERAL WAY BUSINESS
WA STATE CON - •R'S LICENSE•
Pitx5CP9Z91Z y_3b _zv
MAILING ADDRESS . , I ,v1/
APPLICANT /
/
CIS zr ZIPFAX
y�?73
_; ,,f= LINGADDRESS EMAIL
r -
resp individual to esrepon and
respond to all this application)
ZIP
application) ®
concerning
NAME
�, ,,,e -f3',raz '6 z _�5. �
l ;RCN 92 O
roperty Domer.I certify to the best
penaltyo perjury that I am the property owner or authorised
agient of�correct I certify that I will that t o the
with
I my kncertiowledge,
underh .f Peon in support of this permit applicationit IIwilco the
allofapplicable knowledge,the Federal
regulations pertaining to the work authorised by the issuance of a permI laws understand thatttthe
ofFed doe Way remove the owner's responsibility.for compliance with local, state, or fedora
City
issuance of this permit does
the u��ae*t and filed "-�t•`•"-�3tbi.
the i and-defense efen 4�eI which. be ad t y any person,Includi the accuracy of the
but only where such claim arises out of the reliance of the city, including its officers and employees, upon
information supplied to the city as a part of this applicatio
DATE �__ —____5---:-/I-----_
SIGNATURE: - �—�/��/ ���
• kAHandouts\permit Application
Bulletin#100—January
29,2016 Page 1 of 2