20-101036 RECEIVED PERMIT APPLICATION
CITY OF �'`.�
Federal Way MAR 0 6 2020
PERMIT CENTER+ 33325 8th Avenue South + Federal Way,WA 98003-6325
253-835-2607 + FAX 253-835-2609 +permitcentel@cityoffederalway.com
CITY OF FEDERAL WAY
COMMUNITY DEVELOPMENT
PERMIT NUMBER D _ / 0 —/ 0 6 - /4A9
TARGET DATE
SITE ADDRESS SUITE/UNIT#
Cc34, 5 ,.._, a la- ST
PROJECT VALUATION ZONING ASSESSOR'S TAX/PARCEL#
$ ysoor oo 6 7 0 a 4-/ - 9 o Se 7
TYPE OF PERMIT ❑ BUILDING ❑ PLUMBING ❑ MECHANICAL ❑ DEMOLITION ❑ ENGINEERING IRE PREVENTION
NAME OF PROJECT .
02- L,.Ate a/l y C-- J
"/�/i7'Azs. (OOOif
Att c,Ad Lc/Ilt7I-dµ�d /0AAi°i- .144._
PROJECT DESCRIPTION � e.--t
be
Detailed description of work to l j.e Li. A e-
be included on this permit only
NAME PRIMARY PHONE
i r 1-tA2../s-e ir- Z-.•Ai t g- /iiic. i___ Le-
PROPERTY OWNER MAILING ADDRESS E-MAIL
3 (066 cl /) 4 S • t1-.1 ,lhu@el-4156m/ oo
AV-
CITY / STATE ZIP^
LCIA
PHONES 3 -€3.5- •-/;.,2-01•-/;.,2-0NAME C/-r�/ p S /t./� ��l-2S-e) /.7 791--
MAILING
MAILING ADDRESS �j E-MAIL- _ -1
CONTRACTOR
f-'• �O,` /o Qo.re,y•5C-it Z� `�'i-1L.GdlN�-
CIT STATE ZIP FAX (J
74Y0044-40 1AJ-0 9tfoo j ,2._s-3 - 8-a 3 - 4454.9
WA STATE CONTRACTOR'S LICENSE# EXPIRATION DATE UBI#
G//5...z-it!**'9790 z--- g' /2 ( ,�a0 6 00 / 1/S•00 V
NAME PRIMARY PHONE 3'3S'0'J7��
�-`Y Sc� {z �S3 • $3 3--7,1,20
APPLICANT
MAILING ADDRESS E-MAIL
/-'• O- /a X- 6 /S
CITY Ar STATE ZIT., FAX
PW Oa LI-A--10--10 a)le/ yeao( ,as--_? - Ss 33 - ',Ate,l c�
NAME /� PRIMARY PHONE
PROJECT CONTACT . ..4 A S -10 pe /) '-Aki
(The individual to receive and MAILING ADDRESS E-MAIL
respond to all correspondence
concerning this application) CITY STATE ZIP FAX
NAME
PROJECT FINANCING 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 •- - part of this application. /
SIGNATURE: 5
/ DATE 3- - 42 O A-47
PRINT NAME: 27 s f/Ca-n
Bulletin#100-February 19,2020 Page 1 of 2 k:\Handouts\Permit Application