19-104787 RECEIVED
4,16,.......
CITY,
OCT 0 3 2019 PERMIT APPLICATION
Federal Way CITY OF FEDERAL.WAY PERMIT CENTER+33325 8th Avenue South+Federal Way,WA 98003-6325
253-835-2607+ FAX 253-835-2609 +permitcenter(acityoffederatway.com
COMMUNITY DEVELOPMENT
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PERMIT NUMBER i _ I 0 - TARGET DATE Ni q
SITE ADDRESS SUITE/UNIT#
_ f-I C_, I/AwS .
PROJECT VALUATION ZONING ASSESBOR'8 /PARCEL#
$ly, 70 v ® a- I 09 _ °T1L
TYPE OF PERMIT ❑ BUILDING ❑ PLUMBING ❑ MECHANICAL ❑ DEMOLITION ❑ ENGINEERING kFIRE PREVENTION
NAME OF PROJECT SO wsgr\ KIN ,, F re + te-5 L� F 5 — 6 0
PROJECT DESCRIPTION
Detailed description of work to — l l r l /r c 5 S GZ 6�e- FA Sy 5 T e ,n/�
L� S ,-as. ,1 N C.t�� GOC 01
be included on this permit only
NAME \ q PRIMARY PHONE
K'r...\ Co.f\� J r t b ' 1- c� 3
PROPERTY OWNER MAILIN DRESS E-MAIL
CITY STATE ZIP
NAMEe"4eA5 j-el Glut 3l (47/a-$)a--yl ?Yv
MAILING ADDRESS MAIL n
CONTRACTOR / S�10O SE L�cls75al-e ("Jai
S doo r-Ic-le, ,J,,,•�e-s 95Ie.AAens,
cI%5elle-vve �w/9 2193008 FAX n Jrr
LO^�
WA STATE CONTRACTOR'S LICENSE# EXPIRATION DATE FEDERAL WAY BUSINESS LICENSE#
5_2-67-16 11 at /9 PP // / 0.7 / /`1 0 —/00 S?c -
NAME G /9- S rl a PRIMARY PHONE
APPLICANTi7L 1"1 MAILING ADDRESS ✓ E-MAIL
CITY STATE ZIP FAX
NAME _____ MARY PHONE
PROJECT CONTACT 71 C�// `l Ol !"-e 5 (L/a-504-1J 7 q6 -2
(The individual to receive and MAILING ADDRESS ,�cc J -EAWL •
respond to all correspondence /5, 00 56 c�4 S 7j a TG wax S-1-e_ �O r iL• \Hn'`e-S 0251 e.r e ri c,Lo�
concerning this application) C ,✓✓// STATE (iIP FAX �J
e,//e lJ l to ��d v 8 "} i')-
NAME
PROJECT FINANCING 0 OWNER-FINANCED
When value is$5,000 or more MAILING ADDRESS,CITY,STATE,ZIP PHONE
(RCW 19.27.095)
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. C'�
SIGNATURE: — ' DATE le, -- - / /
PRINT NAME: )C)
/ ? cur t7 a'' e. 5
Bulletin#100-January 29,2016 Page 1 of 2 k:\Handouts\Permit Application