19-105790 RECEIVED PERMIT APPLICATION
CITY OF '1•'� DEC 10 2019
PERMIT CENTER+33325 8th Avenue South+Federal Way,WA 98003-6325
Federal ay 253-835-2607 +FAX 253-835-2609+permitcenteolicitvoffederalway.com
CITY OF FEDERAL WAY
COMMUNFTY DEVELOPMENT l
PERMIT NUMBER 9
- f O O - AI/TARGET DATE
SITE ADDRESS SUITE/UNIT#
73 003
PROJECT{ VALUATION ZONING ASSESSOR'S TAX/PARCEL#/
$ 'tel '3; v��C� l 9: 6'- 0 t: 6 ,--:--,
TYPE OF PERMIT ❑ BUILDING ❑ PLUMBING ❑ MECHANICAL D DEMOLITION ❑ ENGINEERING''FIRE PREVENTION
NAME OF PROJECT ,i) P, V TA (S() C,-I p L); i o!`✓
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PROJECT DESCRIPTION _ r
Detailed description of work to } TJ tl--:71 - ,y)(/f ,j <i( 1 ,�(cLi L✓f
be included on this permit only
NAME .. PRIMARY PHONE
DP.-. (---i--:‘,.___=.!•_)c..--- It3-. cki &--2`IcG
PROPERTY OWNER MAILING ADDRESS
C-) I V '_'; ��
CITY , �, STATE ZIP
tDL C-c1-' Co g.2,0 2---
NAME PHONE
PAIC,cc.- fi(72_ Fcc'T--{z .) ___L7'JCi 2:---1-)6 --'7Z) ZZ.0
MAILING ADDRESS ,_ E-MAIL
CONTRACTOR L1 7 C l V) )4`I% ' '
CITY STATE ZrIP� FAX
WA STATE CONTRACTOR'S LICENSE# EXPIRATION DATE FEDERAL WAY BUSINESS LICENSE*
t3C ) 2,( li; 6 g /3f /77
NAME PRIMARY PHONE
., _
,.-) .T i-i G I (. {,' i�Y C V..../..--1 I. Q n ) P",vI'�
MAIMG ADDRESS E-MAIL
APPLICANT ' r, r
CITYr. I STATE ZIP FAX
NAME / PRIMARY PHONE
PROJECT CONTACT ' _<�'- -, ppi h/A� 2.1.„/ `,t .- 2'))--<,U 437
MAILING ADDRESS/ _ E-MAIL
(The individual to receive and ----r"
respond to all correspondence ��' �'1 >�,��� � r. "-�'�,f C- p/z'/,� /
concerning this application) CITY STAT, , ZIP FAX I
NAME
PROJECT FINANCING 0 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: A-7 ,,/7-- )
DATE 2---//�( V--
PRINT NAME: (a�F Z� 41N, 4.),,//.1. ^
Bulletin#100—January 29,2016 Page 1 of 2 k:AHandouts\Permit Application