19-105910 RECEIVED
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CITY OF --- DEC 2 0 2019 PERMIT APPLICATION
e era WayPERMIT CENTER+33325 8th Avenue South+ Federal Way,WA 98003-6325
CITY OF FEDERAL WAY 253-835-2607 +FAX 253-835-2609+permitcenterfa,citvoffederalway.com
COMMUNITY DEVELOPMENT
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PERMIT NUMBER / 9 _ / J111 O `5 / 0 9 TARGET DATE
SITE ADDRESS SUITE/UNIT#
Z a zo S 3-2.0 ilk Si- 5o,'+e (0 6 1 o 6
PROV VALUATION ASSESSOR'STAj+i
TION ZONING /PARCEL#
$ 1 O / O -
T 2- 67
TYPE OF PERMIT ❑ BUILDING ❑ PLUMBING ❑ MECHANICAL ❑ DEMOLITION ❑ ENGINEERING KFIRE PREVENTION
NAME OF PROJECT pT 17o �ipl,i'A ® ✓,/ �;, 1 y� t—I—
PROJECT DESCRIPTION //�,,I/l h"1 T�itk-e"f-1`4,`/1 9-0 f.,.,
- ) g/g4-at Le'van f r
Detailed description of work to /-7 41Y1 KA Ow t i- " �et44-<(e< 4I 14004 5.Aif re4r i'..A
be included on thispermit only cuxek D„-cf 1>Q ,L,p C(evs, f e A t ,•f 04
NAME i' CD lk � k "' L c PRIMARY PHONE
PROPERTY OWNER MAILING ADDRESS ` I E-MAIL
CITY /� STATE ZIP C ( 5.c
NAME LI 3'x0
r 6 e.pc
n (C f / „ .eral PH,36 -3 6 V."9 46
MAILING
CONTRACTOR o O �� , St fi.et e2.51Ma,(t ,Cert,
CITY { STAIE. ZI) g- D FAX
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.WA STAT;GONE c C c) ¶ #3I •EXPIRATION DATE FEDERA,I.WAY/OBVS NESS L1co —#
tyAISNAME PRIMARY PHONE
APPLICANT MAILING ADDRESS E-MAIL
CITY STATE ZIP FAX
---0000 - - ---
NAME I' n y' PRIMARY PHONE
PROJECT CONTACT • S D�rQ r> 2-0 6 -?q i-e. 3 3
(The individual to receive and MAILIBGADDRESS, �/ MAIL I
respond to all correspondence .c:,-j. 14Ytf(4L53/�`( (ma I j C
concerning this application) CITY R. th f STATE., �
ZIP ' FAX
NAME IV�L
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 asppaart of this application.
SIGNATURE: Al-,e W! DATE '` ? Jie?1 5 /
•
PRINT NAME: 4,,Idf. P 4-t(
Bulletin#100—January 29,2016 Page 1 of 2 k:\Handouts\Permit Application