21-101842-SF-BuildingPermitApplicationPg1-5-12-2021-[Version1]CITY OFVAA�L
PERMIT APPLICATION
PERMIT Federal Way MIT CENTER + 33325 81h Avenue South + Federal Way, WA 98003-6325
253-835-2607 + FAX 253-835-2609 + permitcenter@cityoffederalwaycom
PERwr NUMBER 1
a TARGET DATE _ 2l
SITE ADDRESS � rV) S
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SUITE T N
PROJECT VALUA71-
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ASSE SOR'S TAX/PARCEL N /\ ]� %�
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TYPE OF PERMIT
BUILDING ❑ PLUMBING ❑ MECHANICAL ❑ DEMOLITION p ENGINEERING ❑ FIRE PREVENTION
NAME OF PROJECT
IT 1
PROJECT DESCRIPTION
Detailed description of work to
be included on this permit only
NAME
PRIMARY P!is
PROPERTY OWNER
MAt=G ADDRESS
NAMES
PHONE
MAILING ADDRESS
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n
CONTRACTOR
aITY
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FAX
WA STATE CONTRACTOR'S SE f
EXPIRATION DATE
UBI 4
FAME
PRIMARY PHONE.
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MAILINGADDRESS 1 , -_
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MAIL
APPLICANT
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FAX
PROJECT CONTACT
NAME
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PRIMARY PHONE
'r` 447.
MAU"ING ADDRESS } ' �'
J\
MA� j
M
n 1
(The individual to receive and
respond to all correspondence
concerning this application)
CITY
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APA
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FAX
LAN
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PROJECT FINANCING
NAME ' 11
p�
OWNER -FINANCED
When value is $5, 000 or more
(RCW 192Z 095)
MAILING ADDRESS, CITY, STATE, ZIP
PHONE
I cent{ jy 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 ir4l'ormation 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
Wormation supp of d to the city as a pa this application
(
SIGNATURE: DATE
PRINT NAME: ZS- mcs
Bulletin #100 - February 19, 2020 Page 1 of 2 IcUimdoutsTarnit Application