20-100012 RECEIVED
` PERMIT APPLICATION
CITY Of .a.._ ...:::_,..,,..w JAN U 1 2020
Federal Way PERMIT CENTER♦33325 8th Avenue South+Federal Way,WA 98003-6325
Cly 253-835-2607+FAX 253-835-2609+permitcenter citvoffederalway.com
PAI
COMMUNE p y�O avrY
PERMIT NUMBER O _ p Q t - A°V� 6 I 0 TARGET DATE
(- )
SITE ADDRESS 4 0-4.,O cO• 3'L v t'' 5,7- g oirC- /V 6 SIIITE/IINIT M
/ nrit,t vIday lx/i9 ' /06
PROJECT VALUATION ZONING ASSESSOR'S TAX/PARCEL#
$ 6 a(00 fv Z ± O - 1 2 f_ Z
TYPE OF PERMIT 0 BUILDING 0 PLUMBING 0 MECHANNICAL 0 DEMOLITION 0 ENGINEERING KFIRE PREVENTION
NAME OF PROJECT h- o r 7O T WO RL/,7 !t ao`U ggC�s TA u RAM`
PROJECT DESCRIPTION � e u4j7- :hi,"v ssi� i
Detailed description of work to A GP DEO P c p4eiAbec C�-/e$ 10-e-0 v../ Ale,4.e/
be included on this permit only c Lc/ G/Arai'
d' NAME PRIMARY PHONE
PROPERTY OWNER 11 �"/ C Zo 6_ 1123-31
Ce L✓
MAILING ADDRESS MAII.
14f n2 E . pike ST" 464400 a AfideG.US# COM
CITY STATE ZIP
NAS PHONE
- Sr' Fie 50(0 Lrt o'e S, 6 c C-' yis- 84/_ 4l9 oq
MAILING ADDRESS �? .f , / EMAIL R t C iC s 13 ERGq;Ia
CONTRACTOR Z/6 4 0/ O jZJ td// p' /Y e e7 g✓�s r,emd t o .ter rfo ei. Com'
CITA STATE ZIP FAX
J0 01 wri. 'b001'
WA FATE CONTRACTOR'S LICENSE I EXPIRATION DATE FEDERAL WAY BUSINESS LICENSE.
srFIPS V. / 3I to f? -/DJ4 rig -OC
NAME P
HONE
icK e,&RAcc - zlZS=B'V-el i6
APPLICANT MAILLIADDRESS EMAIL
5frIn6 Ai CA,KrRa•N:ToA.
CITY STATE ZIP FAX
E PRIMARY
PROJECT CONTACT N TZ v'`'a'#11 ear.
L I -'i al
(The individual to receive and MAILING ADDRESS �J E-MAIL gg CIC, 13•6/24,<,A
respond to all correspondence /,�/ c9 .L a�piiiOG v tiow r . Ci OM
concerning this application) CITY S•' STATE ZIP FAX
NAME
PROJECT FINANCING u utcc, g_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 el as a of this application.
l
BIGNATURE: �/ DATE `.... .../
PRINT NAME: eg.t GLC
1560c -67.0
b0
Bulletin#100—January 29,2016 Page 1 of 2 k:\Handouts\Permit Application