13-102319 ECEIVED
mor
MAY 2 8 2013
ELECTRICAL
CITY OF
Federal Way CITY OF FEDERAL WAY PERMIT APPLICATION
CDS
PERMIT NUMBER / 3 _ / 2 3 / ' _
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SUITE/UNIT/SPACE#
SITE ADDRESS: :;3325" e6.
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vt, ,
PROJECT VALUATION ASSESSOR'S TAX/PARCEL# CURRENT/PROPOSED USE
$ 00 0 - - - -
PROJEC'i NAME /'
(Tenant or Homeowner Last Name) C
PROJECT DESCRIPTION °�11"0/\' 01 AA 4S,c WA %A-5-r [l
Detailed description of work to
be included on this permit only
NAMEPRIMARY PHONE
PROPERTY OWNER 7," F-20 ) -
MAILING ADDRESS E-MAIL
CITY STATE ZIP FAX
)
NAME PRIMARY PHONE
Cry (5 ) >$L - 270
MAILING ADDRESS E-MAIL
te
ELECTRICAL 33 lam' ' �f 41-e.,1,1 (-2'Yi. (P
CONTRACTOR CITY STATE ZIP FAX
,c) _\ MA or7.L t ) -
WA STATE CONTRACTOR'S LI NSE# EXPIRATION DATE FEDERAL WAY BUSINESS LICENSE#
L.47r1141,1 Or !Ai
NAME PRIMARY PHONE
( )
APPLICANT MAILING ADDRESS E-MAIL
CITY STATE ZIP FAX
)
NAME PRIMARY PHONE
PROJECT CONTACT ( )
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 the city as a part of this application.
SIGNATURE: DATE 5/13/',"
(,"
PRINT NAME:
Bulletin#160—January 1,2013 Page 1 of 2 k:\f{andouts\Electrical Permit Application