21-100011-SF Permit Aplication 01-05-2021-V1PERMIT APPLICATION
CIrY of
PERMIT CENTER + 33325 8th Avenue South + Federal Way, WA 98003-6325
Federal Way 253-835-2607 + FAX 253-835-2609 + permitcentel@cityoffederalway.com
PERMIT NUMBER I l _ t 0 1 — -:5 P TARGET DATE A—U 'ac r 2_Q
SITE ADDRESS
28� 23C)FE AR WAJ 95 3
SUITE/UNIT M
PROJECT VALUATION
TYPE OF PERMIT
ZONING
ASSESSOR'S TAR/PARCEL 8
❑ BUILDING ❑ PLUMBING ❑ MECHANICAL ❑ DEMOLITION ❑ ENGINEERING ❑ FIRE PREVENTION
NAME OF PROJECT
PROJECT DESCRIPTION
Detailed description of work to
be included on this permit only
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PROPERTY OWNER
NAME�a ( A to �-A i`'3s_ /
PRIMARY PHONE
—S IL I �
MAILING ADDRESS
2�32-2-:.0 Is/��rc5
E-MAIL
-g-�_NAl��l�'��lsN,
CITY
l�A
ZIP 9800 3
CONTRACTOR
NAME
PHONE
MAILING ADDRESS y O
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E-KML
CITY
STATE
ZIP
FAX
WA STATE CONTRACTOR'S LICENSE #i
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APPLICANT
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CITY A , `'►1�
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NAME
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PROJECT CONTACT
(The individual to receive and
MAILING w S
7,4V , 5 Ave
respond to all correspondence
CITY Viifl r w /l�
!+
S_ T¢TK
'{l
�i! J
concerning this application)
PROJECT FINANCING
NAME
When value is $5, 000 or more
(RCW 19.27.095)
MAILING ADDRESS, CITY, STATE, ZIP
EXPIRATION DATE 1 UBI #F
PRIMARY PHONE
5'2 21 1 q
fi Ns�, � w15N6
ZIP /�� � 3 FAX
7 PRIMARY PHONE
253 324t 2114
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ZIP �� � � •� FAX
❑ OWNER -FINANCED
PHONE
I cert(M under penalty of perjury that I am the property owner or authorized agent of the property owner. I certjfy that to the best
of my knowledge, the information submitted in support of this permit application is true and correct. I cert((y 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 claing, which may be made by any person, including the undersigned, and flied 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
ir{formation supplied to the city as a part of this application.
SIGNATURE: j DATEf 2G��
PRINT NAME:
Bulletin # 100 - February 19, 2020
Page 1 of 2
k:\I-Iandouts\Pemut Application