20-103444-Building Permit Application-09-08-2020-V1.. PERMIT APPLICATION
CITY OF _
PERMIT CENTER + 33325 8lh Avenue South + Federal Way, WA 98003-6325
Federal Way253-835-2607 + FAX 253-835-2609 +€ rr�itCenie c.: c feed I aiay.co
PERMIT NUMBER _ _
— TARGET DATE
SITE ADDRESS 7
31 s 2 ��� �L , ��e��r way , w� �$D�3
SUITE/UNIT #
PROJECT VALUATION
ZONING
ASSESSOR'S TAX/PARCEL #
TYPE OF PERMIT
X BUILDING ❑ PLUMBING ❑ MECHANICAL ❑ DEMOLITION ❑ ENGINEERING ❑ FIRE PREVENTION
NAME OF PROJECT
L' if -I, e r 4
PROJECT DESCRIPTION
wl oL a4-- e-A Q1L e a C A S O r^ } i n -�iJ a -i O F-
Detailed description of work to
be included on this permit only
NAME
PRIMARY PHONE
PROPERTY OWNER
MAILING ADDRESS G /�1
EMAIL
CITY+C^5 f I�q
�� G�
L
9�aa3
NAME
PHONE
sc)-sc
MAILING ADDRESS
EMAIL
CONTRACTOR
CITY
STATE
ZIP
FAX
WA STATE CONTRACTOR'S LICENSE #
EXPIRATION DATE
UBI #
NAME
PRIMARY PHONE
st ,s►{
APPLICANT
MAILING ADDRESS
EMAIL
CITY
STATE zII+
FAX
NAME
PRIMARY PHONE
PROJECT CONTACT
5 S on
MAILING ADDRESS
E-MAIL
(The individual to receive and
respond to all correspondence
CITY
STATE
ZIP
FAX
concerning this application)
PROJECT FINANCING
NAME
IVA
OWNER -FINANCED
When value is $5,000 or more
(RCW 19.27.095)
MAILING ADDRESS, CITY, STATE, ZIP
PHONE
I certify under penalty of perjury that I am the property owner or authorised 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 authorised 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 Iaws.
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 city as apart of this application.
SIGNATURE: DATE
PRINT NAME:
c._
Bulletin #100 -February 19, 2020 Page i of 2 k:\Handouts\Permit Application