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12-104861 ECEIVED on or• ' rpERM I'� l U V 6 /MF CO ME PL DE EN 0 Federal Way COMMUNITY DEVELOPMENT SERVICES A P P L I C AT t o N 2012 253-835-2607•FAX 253-835-2609 u.2;.11,ri ypfferierohpare..R1 CITY OF FEDERAL WAY CDS SITE ADDRESS SUITE/UNIT# ;4cCI/0 1pe4 4416 S #-103 3 /09 PROJECT VALUATION ZONING ASSESSOR'S TAX/PARCEL# $ , � z S 0 0 9 0 - -0 G 4 o TYPE OF PERMIT ❑ BUILDING ElPLUMBING ❑ MECHANICAL ❑ DEMOLITION ❑ ENGINEERING B'FIRE PREVENTION NAME OF PROJECT (Tenant Name/Homeowner Last Name) le. //a DeI"7 ] PROJECT DESCRIPTION `YP A (a v i,- Zv`S 7 o ( � 1O), TT Detailed description of work to be included on this permit only NAMEI' .! PRIMARY PHONE PROPERTY OWNER j///w NiktipeiteL MAILING ADDRESS E-MAIL CITY STATE ZIP NAME , PHONE NW 6-/mC7I) -iL Se1-U► Ce 24A c 206 l/78 - 9e2 MAILING� ADDRESS �� �E-MAIL _ CONTRACTOR '72 -d /9 3 aV w/ v yo p4` �1 eve,U0 v.,4 6d,(©m CITY , ZIP FAX ,re�ea -Ay a �0o_2_ 3 WA STATE CONTRACTOR'S LICENSE S EXPIRATION DATE FEDERAL WAY BUSINESS LICENSE B kW SLE-&*S i`UL zG /i-7 /_3 NAME PHONE S1,ACt 4c O-Cvv-e APPLICANT MAILING ADDRESS E-MAIL CITY STATE ZIP FAX PROJECT CONTACT NAME PHONE (The individual to receive and respond to all correspondence MAILING ADDRESS 1 E-MAIL concerning this application) /Q"f CITY / /i STATE ZIP FAX 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 ci a p, of this application. SIGNATURE: r DATE i/0 2 —1, PRINT NAME: 7(1047. 0� Bulletin#100-January 1,2011 Page of 3 k:\Handouts\Permit Application