21-105341RECEIVED
CITY OF �� DEC 2 2 2021
Federal Way CITY OF FEDER,4L WAY
COMMUNITY DEy1=LOPMEN
PERMIT APPLICATION
PERMIT NUMBER
3 TARGET DATE
SITE ADDRESS
VALUATION I ZONING I ASSESSOR'S TAX/PARCEL #
SUITE/UNIT #
TYPE OF PERMIT k11UILDING ❑ PLUMBING ❑ MECHANICAL ❑ DEMOLITION ❑ ENGINEERING ❑ FIRE PREVENTION
NAME OF PROJECT _ n P .r _ .. n r,�. _ _ .. _ . _ 9 - O' d i e .'p
PROJECT DESCRIPTION
Detailed description of work to
be included on this permit only
PROPERTY OWNER
NAME
NAME
MAILING ADDRESS
CONTRACTOR
CITY
WA STATE CONTRACTOR'S LICENSE #
NAME
ILLY
APPLICANT MAILING ADDRESS
CITY
PROJECT CONTACT
(The individual to receive and
respond to all correspondence
concerning this application)
PROJECT FINANCING
When value is $5,000 or more
(RCW 19.2R095)
ZIP
— fIP�-//,4 �
STATE ZIP
EXPIRATION DATE
STATE I ZIP
PRIMARY PHONE
2-Aq 6
E-MAIL _
C
PHONE
{{pp gT i
lit A i i
E-MAIL
FAX
FEDERAL WAY BUSINESS LICENSE #
PRIMARY PHONE
Lac
E-MAIL
FAX 114 t CAO G
MAILING ADDRESS E-MAIL
CITY I STATE ZIP FAX
NAME
❑ OWNER -FINANCED
MAILING ADDRESS, CITY, STATE, ZIP I 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 t city as a part of this application.
SIGNATURE: DATE
PRINT NAME:
Bulletin # 100 — February 22, 2016 Page 1 of 2 k:\Handouts\Permit Application