21-102588RECEIVED PERMIT APPLICATION
'�.
CITY OF JUN 2 2 2021
Y PERMIT CENTER + 33325 8� Avenue South +Federal Way, WA 98003-6325
Federal Wa 253-835-2607 + FAX 253-835-2609 + pernlitcentev"u,cityoffederalway.coin
CITY OF FEDERAL WAY
WMMUNI Y DEVELOPMENT
PERMIT NUMBER I _ C
SITE ADDRESS
33c)kI a fiNe Tcck(al W?01 u • c1'�003
PROJECT VALUATION
ZONING
ASSESSOR'S TAR/PARCEL N
TARGET DATE /" 1 N
SUITE/UNIT N
TYPE OF PERMIT 2 BUILDING ❑ PLUMBING ❑ MECHANICAL ❑ DEMOLITION ❑ ENGINEERING ❑ FIRE PREVENTION
NAME OF PROJECT I
Sift �L c M ( l:l
PROJECT DESCRIPTION
Detailed description of work to 0 14&4�r1
be included on this permit only
NAME
-TNrt E MU i H I-o1zA
PROPERTY OWNER i 11LING ADDRESS
3011 2�kve S(Ai
���JLO��� :Jv�� WAE ZIP 1 Cl��•J
—� NAME f1
CONTRACTOR
MAILING ADDRESS
CITY I STATE I ZIP
WA STATE CONTRACTOR'S LICENSE N -
EXPIRATION DATE
NAME
INNIc �1c,�� Lk4fcv� r-_ t W i+I10PL,
APPLICANT
MAILING ADDRESS Sl.�-1
0ii z��'Avg g'
CITY
/� 11. STATE
e rCi4,P- l�,�,�`�
ZIP
NAMi h T1 F
PROJECT CONTACT
(The individual to receive and
MAILING ADDRESS
1 3 3n- I 21 rNv E RAj
respond to all correspondence
concerning this application)
CITY STATE
LA\
—
ZIP
9 3
— --
PROJECT FINANCING
NAME
When value is $5,000 or more
MAILING ADDRESS, CITY, STATE, ZIP
(RCW 19.27.095)
PRIMARY PHONE
E-MAIL
PHONE
E-MAIL
FAX
UBI N
PRIMARY PHONE
E-MAIL
FAX �^ M-�,J
PRIMARY PHONE
E-MAIL
FAX
❑ OWNER -FINANCED
PHONE
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 city as apart
ofthisapplication. r
l.J`-�z`c,� DATE fo '7-�� a
SIGNATURE: Ii"
PRINT NAME:
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