10-102131 ., _l �_ - ��� L -3
� � ���°�''� _'ERMIT
.
Federal Way ��'����r�� L °E E FP
,
COMMUNITY DEVELOPhfENT SERVICES A P P L I C A T I O N �
253-835-2607•FAX 253-835-2609 r�-'�;
uww.d[uoffedemlwau.mm MAY � l ?.�.: ,�
W,��'
3ITE ADDRE38 �� �� �� ��� / ��� SUITE/UNIT M
G- S v �i
PROJECT VALUATIOIQ ZONIN6 ASSESSOR'S TAX/PARCEL#
$ ��,o p � 5 D 0 � 6 _ (� (� � �
TYPE OF PERMIT � B�'DING ❑ PLLJNIBING ❑ MECHANICAL
❑ DEMOLITION ❑ ENGINEERING FIRE PREVENTION
� NAME OF PROJECT 1 I S C O�J�G� L i�-�
enant Name/Homeowner Last Name
PROJECT DE$CRIPTION �/�' �r�P ��
Detailed description of work to a
be included on this permit only
NAME � PRI HONE
PROPERTY OWNER � � (e S L G C �� ��— ���'�
AlAILING ADDRESS E-AlAIL
,� � 4 �o .�, �
s t s S�$ ZIP s 2 ss
,
►�,��1(l�wc�5� � Q 5 f�-�, S p�v� - �72� �'o �
AZAILINCi ADDRESS E-MAIL
3 3�'�.�' /�= S.sr.s��ia � '
CONTRACTOR �
C� STATE ZIP FAR ��-6�t
/v '�v�/� Gt.� �1��`` 0 6 -T?Z�7�
WA STAT&CONTR�A�J�'�Q'8 LICENSE M ERPIRATIOIP DATE FEDERAL WAY BUSINE88 LICENS #
/7��2-t�i G�. ! 2/ � /l
xne�s n �`r � � `G rxo�� z/` //
�`L / <
APPLICANT MAILING ADDRE88 � � � � � ` E-MAIL /�
3 , � !2 ��o� ��l'z 5 S,
CI1R v � STATE ZIP �L FAR���_��� ^ ��.-� � / a N
��� r� 7 -,
PROJECT CONTACT �� e PHONE
(The individual to receive and e� � � rf�
respond to all correspondence �LING ADDRE88 ��y
concerning this application)
CITY STATE ZIP FAR
ALTERNAT6 CONTACT NAME: PHONE E-MAIL
PROJECT FINANCING N�M�
� OWNER-FIIQANCED
Required oalue of$5,000 or more
(RCW 19.27.095) MAILIN6 ADDRE88,C1TY,ST P PHOME
I certtfy under penalty of perfury that I am the property owner or authoriaed agent of the property owner.1 cert{/'y that to the 6eat
of my knowledge, the ir�'ormallon submitted in support of this permit applicatton is true and correct.I certify that I wtil comply urtth
all qpplicable City of Federal Way regulations pertaining to the work authorised by the issuance of a permit. I understand that the
{asuance of this permit doea rtot remove the ownePs responsi6ility for rnmpliance with local, state, or federal Iaws reguiating
rnnstructlon or environmental laws.
I further agree to hoid harmless the City of Federal Way as to arty clatm(tncludtng costs,expenses,and attorneys'fees incurred in
the inveatlgation and defenae o such cla{mJ, which may made 6y any person,including the undersigned,and filed against the city,
but only where such cl ses out of the reiian j the city, including its officers and empioyees, upon the accuracy of the
{►4/'ormation suppl{ed the ty as a of this ap atlon.
\
SIGNATURE: � DATE _� �� "�v
PRINT NAME:�J(,�(� � �iSt'�I2-/�D
Bulletin#100—April 14,2010 Page 1 of 3 k:�Handouts�Permit Application