21-100880-CO- Application-3-8-2021-V1eirYsf"ffi PERMIT APPLICATION
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PERMIT NUMBER
TARGET DATE
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,G*1
SITE A.DDR.ESS
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SUTTE/UNIT #
PROJECT VALUATION$ +taeo c
AssESsoR's rAx/pARcEL # ,Jog?L0f Jylt
TYPE OF PERMIT E Burloruc ! Pt ut',relNc fl Mecuaxlcer- D Deuolrtrow ! trncrNeeRmc ! Frno PREVENTToN
NAME OF PROJECT Seo"t- H.*p oy
PROJECT DESCRIPTION
Detailed description of uork to
be included on this permit onlg
Pel; ru4runt Atzn a +t'iSrlrc ll4utt ta it f
I
PROPERTY OWNER
NAME
Hnn PRIMARY PHONE
MAILING ADDRESS2-'rc--9. 1za.th ti 9vr"le A E-MAJL
"'*ft(,a,l.STATEut)"'q 5o o3
CONTRACTOR
NAME {9D PHONE
MAILING ADDRESS E-MAIL
CITY STATE ztP FAX
WA STATE CONTRACTOR'S LICENSE #EXPTRATION DATE I'BI *
APPLICANT
NAME K; Na.PRIMARY PHONE":zt*i':";iI . fl ?3
MAILING ADDRESStiioE* n;t|4ut ra, .<.tflnlr- h=t,;le"fD llCITY . 'J'frdz',zL t4 STATE
U/d "'7 guo 3 FAX
PROJECT CONTACT
(The indiaidual to receiue and
respond to aLl correspondence
conceming thb appLic ation)
NAME t V
K; P {ttul PRIMARY PIIONE/T?-ht .&vs
MAILING ADDRESSA[,f H'jt:,$q* 'r.-.A, -C,Xi"^f.rJ'-Jc&e {frit,
"'n f-<*t c'u*-STATE
uA^""7 go',?FAX
PROJECT FINANCING
When ualue is $5,O0O or more
(RCW 19.27.09s)
NAME
LJ OVINER.FINANCED
MAILING ADDRF.SS, CITY, STATE, ZIP PIIONE
I certtfg under penaltg of perJurg that I am the Propertg ouner or authorized. ogent of the propertg owner. r certifg that to the bestof,mg knouled.ge, the lnfomatlon submitted. in support of this pemit application is true dnd. "oo""i. I certifg that iuill complg uithau aPplicable citg of Fecleral wag regulatiore pertqining to tie work aitnoazea bg the issuance o.f a pemit. I un4erstand. that theissronce of this permit does not remoue the ouner's resporeibilitg for compliaice :,rlitl. local, Jtoti, o, federal laus regulatingcoretruction or environmental laus.
I further agree to hold. hamless the citg of Fed.eral wag as to anv claim (includ.ing coscs, tr1renses, olnd dttomegs, fees incuned. int::'::i,:r,::::""-:,:L 1.,f:*.-"!-'^:.!.:^^rf!:_y\:?-y:! !: :"a..!u y"v.nlyioa. tnctidins ti. ina"."isi"i, and fited asainst the ctts,
SIGNATURE:
PRINT NAME:
Bulletin # I 00 - February 19, .2020 Page i of2 k:V{andouts\Permit Application
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BOILERS
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Bulletin #100 - February lg,ZOZO Page2 of2 k\Flandouts\Permit Application