12-100704 _L. Ld 0
CITY Or
• Federal Way *ER.0 's j '.
DS , F CO ME PL DE EN P
COMMUNITY DEVELOPMENT SERVICES A P P L I - N
2530-8!63:
2601 P45 253 835-2609 /
,, rf qc,..,,. FEB 1 5 n'a 13
m
SITE ADDRESS CITY OF FEDEQ,`�� SUITE/UNIT#
3 ys 72 1� y/, , i'& s 1 cDs s
PROJECT VALUATION ZONING ASSESSOR'S TAX/PARCEL#
$ /01 0OC7 b - (Doc-0_
TYPE OF PERMIT ElBUILDING ❑ PLUMBING CIMECHANICAL
El DEMOLITION ❑ ENGINEERING IXFIRE PREVENTION Fr iqb AGM2yyt
NAME OF PROJECT
(Tenant Name/Homeowner Last Name) ✓/� 61 lgEL6-6s
PROJECT DESCRIPTION /fid 'SF 86 7,97L 5Pi , AD d/A✓Cr 0Ai
Detailed description of work to Sm.eo c e &-v/Vz 7d '71/ C--)c/S7//1'4 Fi 6
be included on this permit only 14?--1/ YS7om„/,
NAME
PRIMARY PHONE
PROPERTY OWNER r u rn- (.() A..1 in f/(C' Q` GL 6
MAILING ADDRESS / E-MAIL
S"7713 cv/2SA 4-v'
CITY / ��/t I/ /�-�e STATE ZIP
W 7v/IfsG Y /j'7%r '`4 C//
NAME_ PHONE
r )C E2 E C L .)-S3 -lis}-o S-Va-
MAI �N!/ F�S
G ADDRS 3 O E-MAIL
CONTRACTOR U Ilf1!O 40
Z CITY
r STATE mmme FAX
ef— d
WA STATE CONTRACTOR'S LICENSE# EXPIRATION DATE FEDERAL WAY BUSINESS LICENSE#
/ /
`,
NAMEi-. 1 6�y,ef; PHONE 3-, 6 -v syo
APPLICANT MAI ING ADDR S!l//� E-MAIL
Po 80 x 63 0
CITY STATE ZIP FAX r) ,- 643g1_
PROJECT CONTACT NAME �L� i� —1)4 /6 /€2/c PHONE
(The individual to receive and /4''m/�/ )'^ ` 6` C 3 -iJ¢ �-as-90
� Q
respond to all correspondence MAII,ING ADD S E-MAIL
concerning this application) Q ,4 603 0
CITY
/' STA
TE
FAX
i7- 9�v3S 63 -cf3`/- to/39
ALTERNATE CONTACT N• „ • •.ONE E-MAIL
PROJECT FINANCING • 'I E
0-Jam•1 /_ 3 7_ / [ OWNER-FINANCED
Required value of$5,000 or more ICJ l �D -j
(RCW 1 9.27.095) MAILING •.•DRESS,CITY,STATE,ZIP PHONE
I certify under penalty of perjury tha •m the property owner or authorized a t of the •roperty owner. I certify that to the best
of my knowledge, the information submitted i ••ort of this permit application is t •nd correct. I certify that I will comply with
all applicable City of Federal Way regulations pertain • - , . . . .• - . • •y the issuance of a permit. I understand that the
issuance of this permit does not remove the owner's responsibility for compliance with Iocal, 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:` r�4 / / DATE —/��/�
PRINT NAME: /f - / %
Bulletin 11100—January 1,2011 Page 1 of 3 k:\Handouts\Permit Application