10-101857e a
Federal l Way PERMIT
F
COMMUIUTY DEVELOPMENT SERVICES
253-835-2607• FAX 253-835-2609
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APPLICATION,ol MAY 0 6 2010
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CITY OF FEDERAL WAY
SITE "DRESSS] (� / I k (a y}�n /y/� y l` n' /� 2 C ITE/UNIT #
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PROJECT VrxALLUJATIONJ�
ZONINGASSESSOR'S TA/X/' //PARCEL �/// #�i�(/t�)
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Cir/BUILDING ❑ PLUMBING ❑ MECHANICAL
TYPE OF PERMIT
❑ DEMOLITION ❑ ENGINEERING ❑ FIRE PREVENTION
NAME OF PROJECT
(Tenant Name/Homeowner Last Name)
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PROJECT DESCRIPTION
Detailed description of work to
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be included on this permit only
PROPERTY OWNER
NAME
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PRIMARY PHONE
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MAILING ADDRESS
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E-MAIL
CITY
STATE ZIP
NAME +DY �$� n ��
PHONE
MAILINGA
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E-MAIL
ONTRACTOR
CITYSTA E
ZIP
q�D1Z
FAX
WA STATE CONTRACTOR'S LICENSE # EXPIRATION DATE
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NAME
FEDERAL WAY BUSIMmq MCINSIZ 0
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APPLICANT
MAILING ADDRESS
E-MAIL
CITY
STATE
ZIP
FAX
PROJECT CONTACT
(The individual to receive and
NAME
PHONE
MAILING ADDRESS
E-MAIL
respond to all correspondence
concerning this application)
CITY
STATE
ZIP
FAX
ALTERNATE CONTACT NAME: PHONE
NAME
E-MAIL
OWNER -FINANCED
PROJECT FINANCING
Required value of $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 of the city, including its officers and employees, upon the accuracy of the
information supplied to��the apart of this application.
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SIGNATURE: \ �y �/I'Y} Gil%' DATE J
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