11-101404 II
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CITY OF l PERMIT RE w EN FP
Federal Way
COMMUNITY DEVELOPMENT SERVICES AP P LI CAT I O N
253-835-2607•FAX 253-835-2609 APR
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iuww.rinjot7cdernhuatt.com t ^ ____�/rFA„, ��� � r . H r+ [�i€1
SITE ADDRESS }fit'1/raj (�/J/�"/7- CITY OF FE D E LNWJ\Y
4 r'' AtAe S }-ec;�c....r�,tk coa. / W R Q$Oo.cDS
PROJECT VALUATION ZONING ASSESSOR'S TAX/ ARCEL#
$ Si C(00 C( Z 6 5— 0 c-) _ d 0 0
TYPE OF PERMIT ❑ BUILDING ❑ PLUMBING ❑ MECHANICAL
❑ DEMOLITION ❑ ENGINEERING )4 FIRE PREVENTION
NAME OF PROJECT
(Tenant Name/Homeowner Last Name)
EVEr5"2-e1" COV‘
p e C -
PROJECT DESCRIPTION
Detailed description of work to y J%P1Fi nei i ' r i.jS
be included on this permit only Oo LJ
-
NAME _ _. ..... PRIMARY PHONE
PROPERTY OWNER L ept Etat
MAILING ADDRESS E-MAIL
CITY STATE ZIP
NAME ,.."—•
44t2M Se —I+if P �035,12
35QI2 68
MAILING ADDRESS} ��,,`Q E-MAIL r 1'�1e e
CONTRACTOR I i S • `'� gtiAr 41 ct.v)se c . 1� .t�rh
CITY AX
S e4ft& STATE ZIP `',,l ti `i F/ 7__[13 41 9128
WA STATE CONTRACTOR'S ` 8 EXPIRATION DATE FEDERALE • WAYDBUSINESS LICENSE A
NAME RN ei I 1Ki � PHONE(2c`O) 351 1 1-68
APPLICANT MAILINGiADDRESS E-MAIL P i�Ie.
l / S14- �.c+).A O- ia4nSe_uu14{13 • LO
yvl
/� AXf J
CITY S-e ct ,, `@ STA ZIP 9 t 133 FAX
.i f.:'�l ?ti ` !e[LC]
PROJECT CONTACT NAME ,Y, ,F,t 1` PHONE
Ivti�ttr-A t 1
(The individual to receive and
\.. t1e_ 1(
respond to all correspondence MAILING ADDRESS +I E-MAIL
concerning this application)
CITYI I STATE ZIP FAX I 1
ALTERNATE CONTACT NAME: PHONE E-MAIL
PROJECT FINANCING NAME 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 as a part of this application.
SIGNATURE: 12.a (?1 �'- DATE 0 9 / ' 1
PRINT NAME: eetTL ki C'`{
Bulletin#100—January 1,2011 Page 1 of 3 k:AHandouts\Permit Application