11-101343 It
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Federal Way PERMIT SF k ,• FP
"reCOMMUNITY DEVELOPMENT SERVICES I I /I ri��
APPLICATION
253-835-2607•FAX 253-835-2609
www.:tuo)ederrdwvay.emn
SITE ADDRESS
CITY ®0 Rgtikit `W',�y
33 05 8{" SIVE , 60077-1 tg§ rY/�VK1nlY
PROJECT VALUATION ZONING ASSESSOR'S TAX/PARCEL M
21,000. " q 2 �' o 0 _ 0 0 6 a
TYPE OF PERMIT ElBUILDING ❑ PLUMBING 0 MECHANICAL
0 DEMOLITION 0 ENGINEERING "FIRE PREVENTION
NAME OF PROJECT
(Tenant Name/Homeowner Last Name) w A OR p 4-101-12-0 O R0
I
PROJECT DESCRIPTION Q�`\• 1 S E rr X I S Ti 1 J(i F 1 17/e. S P 21 til -LLE H E,1 0 L J CA rl C AJ
Detailed description of work to -rc I1CA ) t,JALk_ l.I3,'rOUr. C1) iNss-r-t .(. ',Jet.-) PE-GIac-no, J'Ya-rc
be included on this permit only
I/.! .se-e-vice_ Rte. tt IT fz.00A-1, (.3) iµ.STW to AIL 4,1 3-1,e-/ e..
P•po_iC, AND Her-LD Lt-t 1` ex IS-/sl(i P--0,4•
NAME PRIMARY PHONE
PROPERTY OWNER
MAILING ADDRESS E-MAIL
CITY STATE ZIP
NAME PHONE
Ile.CNc-:. CCI-i•r e cic-rw,J , ,/.1c_ 253'9.72.'1222
MAILING ADDRESS E-MAIL P 9e LGA►D O
CONTRACTOR Q'SS 5. _ote fiti .St, 4l,'r✓/z-eciosr/Zuc11CJ.c i
CITY STATE ZIP FAX
Ker i✓<) 9eC3T.. 431•$ 2.12-7I
WA STATE CONTRACTOR'S LICENSE it EXPIRATION DATE FEDERAL WAY BUSINESS LICENSE M
1412.0NEI - 219 DE- y / 1 /•LCIZ 2C-0o-1C1411o3 Co SL-
NAME PHONE
'Pc.-cc 2 PELo A Do 253'' 12' 1222
APPLICANT MAILING ADDRESS E-MAIL 1,0E,0,7 s.*pc, (a
ie55 3. Ro(ofti J 1. aecrice_CWs1z4.1c.T7C&/. et)4,1
CITY STATE ZIP FAX
Keti/r w)A 9,032 253 .8"12.72-1'I
PROJECT CONTACT NAME PHONE
(The individual to receive and PETE-IZ S7ELt, A Do
respond to all correspondence MAILING ADDRESS E MAI
concerning this application)
CITY STATE ZIP FAX
ALTERNATE CONTACT NAME: PHONE E-MAIL tIGK Q
ag4.r4-c g-e()&167-444.c.7i Gra. u1/vl
PROJECT FINANCING NAME
0 OWNER-FINANCED
Required value of$5.000 or more
(RCW 19.27.095) MAILING ADDRESS,CITY,STATE,ZIP PHONE
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 ats a part of this application.
SIGNATURE: DATE / / 2 1'
PRINT NAME:_—( 1 JL TL 4 ,)LCL (i
Bulletin#100-January 1,2611 Page 1 of 3 kAllandouts\Permit Application