09-102938Cl" OF <.
Federal Way
COMMUNITY DEVELOPMENT SERVICES
253-835-2607• FAX 253-835-2609
PERMIT
APPLICATION
SF MF CO ME EL PL DE EN P
�r
- _ PROPERTY
SITE ADDRESS T-A *Pe
SUITE/UNIT #
ZONING
ASSESSOR'S TAR/PARCE #
PROJECT
NAME OF PROJECT
(Tenant or Homeowner Name)
i� C /L�-L ��� Cif-ccE
❑ BUILDING ❑ PLUMB G ❑ MECHANICAL
TYPE OF PERMIT
❑ DEMOLITION ❑ ELECTRICAL ❑ ENGINEERING )!� FIRE PREVENTION
:I L G L C
PROJECT DESCRIPTION
Detailed description of work to
be included on this permit only
c�
PEOPLE
PROPERTY OWNER
NAME
F C D L %�i/?� L 4�J %T IG �� I- ,)�Lc - L C C-
PRIMARY PHONE
S� C 8 �D� 1� 0 6
MAILING ADDRESS, CITY, STATE, ZIP ` S 7 [•�Rj jc-
E-MAIL
3 Cb P- L/6Cz SJ-1 C6 � �e
❑ CONTRACTOR ❑ APPLICANT PROJECT CONTACT
OWNER IS ALSO:
NAME`-
PRIMARY PHONE
CONTRACTO 6
MAILING ADDRESS, CITY, STATE, ZIP �,• yA1�� (LL�•
"~
FAX
z33 8 13J"'
3�
31.zs o l , c
-
�� U
WA STATE CONTRACTOR'SLICENSE #
.g
IRATION DATE
FEDERAL Y AUSMESS LICENSE #
n�-1ozg3�-oe
�N4b z z
�z� �z�
NAME
PRIMARY PHONE
APPLICANT
MAILING ADDRESS, CITY, STATE, ZIP
FAX
PROJECT CONTACT
NAME
PRIMARY PHONE
(The individual to receive and
a l C' LC. Cr,- .C�
ZZ.S 6 F - /7
MAILING ADDRESS, CITY, STATE, ZIP O 1� 1`11
FAX
respond to all correspondence
concerning this application)
11 Vx� C. Le Cti� �6 36�
_
ALTERNATE CONTACT NAME:
PRIMARY PHONE
E-MAIL f�iJ J•-���
PROJECT FINANCING
NAME
❑ OWNER -FINANCED
Required for projects with
MAILING ADDRESS, CITY, STATE, ZIP
PRIMARY PHONE
value of $5, 000 or more
(RCW 19.2ZO95)
I cerWy 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 Warmation submitted in support of this permit application is true ar+ld correct. I cert4 fy 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 supplie to the qity apart of this application.
1\
SIGNATURE: I DATE
PRINT NAME: k, 6, ;r4
Bulletin # 100 - 7/28/2009 Page 1 of 4 k:\Handouts\Permit Application