11-101573 ,100,
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ssor \14\04PERMIT F CO ME PL DE EN FP
Federal
COMMUNITY DEVELOP VICES P; P��K A T I O N �c t SS u� -ie
253UNI
COMMUNITY
FAX 2 3-835-2609 V
ugl...0._rjsoffrderolwait Com 0)N `n'
t•1G ��DeA��V`�
SITE ADDRESS `�' SUITE/UNIT#
O
33 y o 1 814 v1 S Fe?.e.44/ w , IdA ?iev,
PROJECT VALUATION ZONING ASSESSOR'S TAX/PARCEL it
$ 9z &.
5- Oo _ 00 6o/2, goo
TYPE OF PERMIT ❑ BUILDING 0 PLUMBING ❑ MECHANICAL
❑ DEMOLITION 0 ENGINEERING g FIRE PREVENTION Fr,. 44,3/CAI
NAME OF PROJECT /
(Tenant Name/Homeowner Last Name) /�/�D PN f7 K,
4 l 2 /�
PROJECT DESCRIPTION ,4/A� m S Pe r ec rfo,J Sy Sr eft, /bit ffe- Ac Tro,J -5r4 r.okk
Detailed description of work to 5/_sr e M, SE 21/e,t 4 o 0," xt„,Q/// 1 .5cvrh $e,v eft ?yy.
be included on this permit only
NAME PRIMARY PHONE
PROPERTY OWNER Al oR p, o 7-4 R k
MAILING ADDRESSE-MAIL
334/05'. cr`A 'TV.:
CITY STATE ZIP
Fe>eea/ a/Ay it)4 997 'o3
NAME / PHONE
fi1eyAA/?eg 6-0 Lt ) f1.46- (Qvre#Ne#)r ;24'b- 63z -- ZQ/Z'
MAILING ADDRESS E-MAIL
CONT C OR l916 •' Nk) .17.ee 5T 664(v/zv AD 6-.0WFi11 rC0K1
i , CITY STATE ZIP FAX
"j`Ot�4{/4 Ak 5e.4IJA 91P 07 7a6- 633- 4f311V�v WA STATE CONTRACTOR'S LICENSE# EXPIRATION DATE FEDERAL WAY BUSINESS LICENSE#
— /11-i7,4 frfo97 41.4) g / 40 //1
NAME PHONE
54..1E fix 4,o vE
APPLICANT MAILING ADDRESS E-MAIL
CITY STATE ZIP FAX
PROJECT CONTACT NAME PHONE
LA,� eF o CA 1 , lob- o
(The individual to receive and / 9' 7�0
respond to all correspondence MAILING ADDRESS E-MAIL
concerning this application) I'1.3&P N k) 534, LS:. le A L%/D q7 6-00F;te,Com
CITY STATE ZIP FAX
SGA 1-7 /c t)4 ir/07 Zoe - 433 -(0Y39
ALTERNATE CONTACT NAME: PHONE E-MAIL
Kev;si riluilcaJ
PROJECT FINANCING NAMEEl 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.
6,>--•.= .
SIGNATURE: il� - �/DATE ] 2-G /20 d ii
PRINT NAME: L A-AI et C4/V,4
Bulletin#100—January 1,2011 Page 1 of 3 k:\Handouts\Permit Application