20-101289 - PERMIT APPLICATION:k,
CITY OF
Federal Way
PERMIT NUMBER
SITE ADDRESS
;)s�s ca
PROJECT VALUATION
$ Cf z
TYPE OF PERMIT
NAME OF PROJECT
PROJECT DESCRIPTION
Detailed description of work to
be included on this permit only
PROPERTY OWNER
PERMIT APPLICATION
PERMIT CENTER + 33325 81h Avenue South + Federal Way, WA 98003-6325
253-835-2607 + FAX 253-835-2609 + permitcentel@cityoffederalway.com
TARGET DATE
SUITE/UNIT #
3 r�ec e
ZONING ASSESSOR'S TAX/PARCEL #
,BUILDING ❑ PLUMBING ❑ MECHANICAL ❑ DEMOLITION ❑ ENGINEERING ❑ FIRE PREVENTION
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NAME
MAILING ADDRESS
S
MAILING AA RESS -
CONTRACTOR C\\,Y•on eA A
CITY
1
WA STATd CONTRACTOR'S LICENSE #
APPLICANT btAILINd ADDRESS
PROJECT CONTACT Ma
(The individual to receive and MAILING
respond to all correspondence Gcn
concerning this application) JY
s D
NAME
PROJECT FINANCING
When value is $5,000 or more MAILING ADDRESS, CITY, STATE, ZIP
(RCW 19.27.095)
ZIP
PRIMARY PHONE
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55
E-MAIL
ZIP ` p'
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EXPIRATION DATE UBI H
,PRIAIA4,Y PHONE
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E-MAIL
STATE I ZIP
YYe
E-MAIL
ZIP
❑ OWNER -FINANCED
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 ivill 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 farther 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 employnas, upon the accuracy of the
information supplied to the cit a part of this liration. '7�
SIGNATURE:
DATE ✓
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Bulletin #100 — February 19, 2020 Page 1 of 2 k:\Handouts\Permit Application