19-105917 i DEC 202019
CITY OF PERMIT APPLICATION
Federal Way CITY OF FEDERAL WAY ERMIT CENTER+ 33325 8th Avenue South + Federal Way,WA 98003-6325
COMMUNITY DEVELOPME 253-835-2607 + FAX 253-835-2609 +permitcenter@cityoffederalway.com
PERMIT NUMBER FP
-�-1 - TARGET DATE
SITE ADDRESS SUITE/UNIT#
"3c->9z-2 6-,*' Lett 5v\/ , Eta) \tA-1 ,\ f\( A �' go 1._c) I---
I (
PROJECT VALUATION ZONING ASSESSOR'S TAX/PARCEL#
$ 0D0. 1 7. pc, if 6 r1
9 u - D [ i (J
TYPE OF PERMIT ❑ BUILDING 0 PLUMBING 0 MECHANICAL ❑ DEMOLITION ❑ ENGINEERING XFIRE PREVENTION
NAME OF PROJECT 1 ` 4 LK1 Ra -tLA >
PROJECT DESCRIPTION {� l
•
Detailed description of work to 51)t L`✓ i--\ 1 tv 17 t L-'1 _f5) MAX-
be included on this permit only
NAME _ PRIMARY PHONE
Kts - L> i . 4--,i WALL I4 Ltom:- zio -,m,- .) 4 7
PROPERTY OWNER MAILING ADDRESS E-MAIL
1011 2-C rJ1 Pi-. �' ' W:S tC: ..rPRE-q 6
CITYio STATE ZIP. , _
L ',j 1. tis A. �tr„,t` Cu iC'1�')! , Uhl
NAMEDI , , PHONE
1j � N'konJ i 0 I � -5,41,4 .--
MAILIGADDRESSE-MAIL
_
CONTRACTOR C.)•Q,n‘- !\S A \JE1 6iLLC`. I 4v
CITY STATE ZIP
FAIL '"
�L''D(0,Ccs
WA STATE CONTCTOR'S LICENSER a EXPIRATION DATE FEDERAL WAY BUSINESS LICENSE#
NAME _ 04,,,-
�� PRIMARY PHONE
..f 4L i kEl l j `-.(V3its i, Ji4 ili
APPLICANT MAILING A��DDDRESS /0F
MC A5
CITY STATE ZIP FAX
PRIMARY PHONE
PROJECT CONTACT
MAILIN(The individual to receive and L
respond to all correspondence r
concerning this application) CITY STATE ZIP FAX
NAME r
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 reliancethe city, including its officers and employees, upon the accuracy of the
/
information supplied to the city as a part of this applic•' •n.
SIGNATURE: _ _ A (1I' V DATE w
PRINT NAME: \f t I M L i; tiee tP..-r
• , I
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Bulletin#100–January 29,2016 Page 1 of 2 k:\Handouts\Permit Application