19-105916 „,.....4.... DEC 2 0 2019
CITY OF PERMIT APPLICATION
Federal Way CITY OF FEDERAL WAY PERMIT CENTER+ 33325 8th Avenue South + Federal Way,WA 98003-6325
COMMUNITY DEVELOPMENT 253-835-2607 + FAX 253-835-2609 +permitcenter@cityoffederalway.com
PERMIT NUMBER / //( %_ / C5 0 / Y-' _ r- ;-
TARGET DATE \
SITE ADDRESS SUITE/UNIT#
PROJECT VALUATION ZONING ASSESSOR'S TAX/PARCEL#
$ '3 CDC). '12C)0 )) 6 1 90 _ 0 �` I 0 5
TYPE OF PERMIT ❑ BUILDING 0 PLUMBING 0 MECHANICAL 0 DEMOLITION 0 ENGINEERINitRE PREVENTION
NAME OF PROJECT j'r 1IZI-DR /,KE R, LA,t o
PROJECT DESCRIPTION { , _
Detailed description of work to f uI C`J f\ 1 t•I 1`"f L . . i� lL-'1 '5 i
be included on this permit only
NAME _ - �_PRIMARY PHONE
irtiSR-Q - L/a'c.f. .1 i t.�L- t41) t_ 20.-1(>1”. '74 7
PROPERTY OWNER MAILING ADDRESS E-MAIL
VISMCZAFPRI—LI 6.)._
CITYiy, t t `STATE ZIP.r, '�/� 1}
-. ... ` .L v :"�.� Y`-�'!"�r;. �(. ,,.. ,,�" �'--t/Crl.('/ )C Dict'
NAME
y PHONE y^
MAILIGIIZII' E-MAIL
ADDRESS ECONTRACTOR C5:41A 1\5 M('-')\10 ►LL Re4445
CITY STATE ZIP FAX ,sA 1ic;?1 0+CC*
WA STATE CONTCTOR'S LICENSE# EXPIRATION DATE FEDERAL WAY BUSINESS LICENSE#
NAME.✓ _._...
1 C kE'' C t D i C PRIMARY,ZA''E
1 0i`'. •rr/1"
APPLICANT- MAILING ADDRESS E-mAx
CITY STATE ZIP FAX
NAME
PROJECT CONTACT
(The individual to receive and
respond to all correspondenceA. t
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 .f he city, including its officers and employees, upon the accuracy of the
information supplied to the city as a part of this applic• .n.
1
SIGNATURE: (1/1/h ' DATE GZ(ZO l L ?„
PRINT NAME: LOLA, t. frt. M`L 1.
Bulletin#100—January 29,2016 Page 1 of 2 k:\Handouts\Permit Application