19-103216 L — ' C _-) c
CITY OF A PERMIT SF MF CO ME PL ''DE EN FP
Federal Way
COMMUNITY DEVELOPMENT SERVICES APP LI CATION RECEIVED
253-835-2607•FAX 253-835-2609
W W W.Cal/Offederalwau.Com
JUL 0 3 2019
SITE ADDRESS CITY OF F>_DERI�
COMMUNITY DEVE T#
i t q S 351" St
PROJECT VALUATION ZONING ASSESSOR'S TAX/PARCEL#
$
7,OC)C, 2. r ' 1 o y - 9 sz
TYPE OF PERMIT BUILDING ❑ PLUMBING ❑ MECHANICAL
❑ DEMOLITION ❑ ENGINEERING })Q FIRE PREVENTION
NAME OF PROJECT
(Tenant Name/Homeowner Last Name) 1-l 1 1- 3 Li sis
PROJECT DESCRIPTION x v%statt:v1 yv,tsC • FH elk,V i(QS Cr rl vdecl it
Detailed description of work to Wgre teun L&S.t +1 t{. •
be included on this permit only
NAME PRIMARY PHONE
PROPERTY OWNER51-1- 3 tQ- 5
NGu tnn-P y er �tv�BLr 1 Vit) Tn C' 253- 9
MAILING ADDRESS J E-MAIL
226Lv 9B'fh i1 5
CITY STATE ZIP
to-ein+- u90k 9801
NAME PHONE
o1setn .0er4-He. T,.,e 253- $"12-1905
MAILING ADDRESS E-MAIL
CONTRACTOR 325' WaStn',vlq h,v, Ave_ 5 `f l
Take 4511-e OlSen etec�hMc.vt€#
CITY J STATE ZIP FAX
cele t- IA)& 98032
WA STATE CONTRACTOR'S LICENSE# EXPIRATION DATE FEDERAL WAY BUSINESS LICENSE#
C)IS-2h ET 61_31 Pe I c / 5" /2049
NAME PHONE
QA/gr, Swt36" 253 - el/ 1405
APPLICANT MAILING ADDRESS J E-MAIL
325 tA..)&5in\1^43 btn A VI 5 1; 91 i oras ie.6 otuv,6tecirIe.v.c,t
CITY STATE ZIP FAX
Icev,i' via. cl e032
PROJECT CONTACT NAME PHONE
(The individual to receive and Lr,`L. 5 LOSS 253 - 81Z-Agog-
respond to all correspondence MAILING ADDRESS E-MAIL
concerning this application) 32.5 wua,Sill v,n,kGv1 Ave 5 *k 91 -rz s IC.e DI c.nE��P iI:.rie T
CITY .J STATE ZIP FAX
ictt t4* I4, CISo 32
ALTERNATE CONTACT NAME: PHONE E-MAIL
PROJECT FINANCING NAME OWNER-FINANCED
Required value of$5,000 or more
(RCW 19.27.095) MAILING ADDRESS,CITY,STATE,ZIP PHONE
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.
SIGNATURE: rr..A — �� - DATE 1/2/Zol9.
PRINT NAME: 7 < _ lee, -
Bulletin#100-January 1,2011 Page 1 of 3 k:\Handouts\Permit Application