10-103310 �� ) �'��- �2.��/ �
��ry� � ��� PERMIT SF MF CO ME EL PL DE FP
Federa�'�I�i
COMM[IN11Y DEVEIAPMENT SERVICES �� J ������I CAT I O N / /
253-835-2607•FAX 253-835-2609(� �
iuu�u�.cituof(ederrilwau.mm f`� A�
r•�
c� , �,,� � t.
; � � F ,; s
� � � �, ���i��: " �� ��s.
SITE ADDRESS
�YY28 (l,ry � v�,..�. �o��qL r� (.J� g��3 �vg'��.
SU1TE/i7NIT# ZOIVING � A3SESSOR'S TAR CEL A
.,.
� �� Z � �' � � � - O c� Z c�
s F � � � ��� �. ���,
�, �t:. �� � �� �� � � s��
, ,,,, .. .. .. : .... , .... .
NAME OF PROJECT �
(Tenant or Homeotuner Name) =->�S C OU/�>> TI�E
❑ BUII,DING ❑ PLUMBING ❑ MECHANICAL
TYPE OF PERNIIT
❑ DEMOLITION �ELECTRICAL ❑ ENGINEERING ❑ FIRE PREVENTION
,�s;� r�1 �� � 2- LAe s�E
PROJECT DESCRIPTION
Detailed description of work to �
be included on this permit only ��
I_y
: � ,
;: ' . , s ;� �� , r �
�� �
.,�,.... ,.. :, ,•. , .��....:� ..:-,. .:�`
�� y� ��
,
,, � � ri „ �
� � �:' � ,., �,' ' �, r,.
� NAME � PRIMARY PHONE
PROPERTY OWNER j�ISGO(,l N J ^I�� C C�,?-�(PAiv` � � -
MAIIdNGADDRESS.CITY.STATE�ZIP p�,p�� E-MAII.
/
�z o�T e���K �a-�kw,� �?NEL wa
OWNER IS ALSO: � CONTRACTOR APPLICANT � PROJECT CONTACT
NAME PRIMARY PHONE
Ev�� � Fi�� A LD�2N1S G L�i (�S3 )(027 -3�9
CONTRACTOR M�'�G ADDRES3.CITY,STATE,ZIP FA%
z�� s�.�na �" sT���i i�<o�� ��- qgya ��zs-3)�z� - ��ec� .
. � WA STATE CONTRACTOR'S LICENSE B EXPIRATION DATE FEDERAI.WAY BUSINESS LICENSE k
c`vE�z . FA QS L D(a /C�`6 /2o�Z �20-u"L�/v zl-vo--BL
NAME PRIMARY PHONE
APPLICANT � tJ C% ��53 )ln�� -3 �`�'
MAII.IN ADDRESS,CITY,STATE,ZIP FAR
a7ac7 �u%// S s;e�r-`-�ar�,;�a wA �3'k�/c czs3 )�z� - 7�a
PROJECT CONTACT N� PR�nxY rxox�
('17ie indiUidual to receive and �-Q`��� (Z 5 3 � /J z 7 - 3'�7 y
respond to ali correspondence nswu.nv wnnx�ss,ctrf,srnrE,zs Fax
conceming this applicationl a(7 �;tTF` S72-E�j`'—A A t,.�p. 9$`! (Z"S�) �L'J- �lvU 7
ALTERNATE CONTACT NAME: P Y PHONE �MAIL
� � -
PROJECT FINANCING N�
� OWNER-FII�iANCED
Required for projects u�ith
uniue of$5,000 or more MAILING ADDRESS.CITY,STATE,z� rxnuxY�oxE
(RCW 19.27.095) r 1 _
1 1
I certiJy under penalty o,f pery'ury that I am the property owner or authorized agent oJ the property ou�ner.I cert}fy that to the best
of mg knowledge, the ir4j'ormation submitted in support oj this permit application u true and rnrrect.I cert4fy thdt 1 will compty with
all applicabie GYty of Federal Way regulations pertaining to the work authorized by the issuance of a permit.I understand that the
issuance o,f this permit dces not remove the owner's responsibility for compliance urith (oca(, state, or federal la�vs regulating
construcrion or environmental icuus.
I further agree to hold harmless the City ojPlederal Way as to ang claim rncluding costs,e�epenses, and attorneys'fees incurred
in the investigatio and defense of such ciair►q, u�hich may be made by any person, including the undersigned, and filed against the
city, but oniy whe such c aim of the reliance of the city, including its o,(�cers and employees, upon the accuracy of the
i�j'ormation suppl"d to th ity as p of this application.
SIGNATURE: DATE d C>Z- .2���
PRINT NAME: l�y C�A N i=
Bulletin#]00-January 1,2010 Page 1 of 4 k:�I-Iandouts�Permit Application