HomeMy WebLinkAbout15-102139` MAY 0 5 2015 ELECTRICAL
CITY OF
Federal Way MY OFED RAL WAY PERMIT APPLICATION
PERMIT NUMBER �� _ / U 2
SITE ADDRESS: 320�1
SUITE/UNIT/SPACE#
PROJECT VALUATION
$ % �Oc)
ASSESSOR'S TAX/PARCEL #
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CURRENT/PROPOSED USE
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PROJECT NAME .
(Tenant or Homeowner Last Name)
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PROJECT DESCRIPTION
Detailed description of work to
be included on this permit only
PROPERTY OWNER
NAME
LA �e- & zit
PRIMARY PHONE
(S�)
MAILING ADDRESS
E-MAIL
1135 ,fir pr Dr
CITY
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STATE
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ZIP
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FAX
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NAMEPRIMARY
PHONE
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(ZO>o) 3Z$- 3z -K45
MAD.DYG ADDR S
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E-MAIL
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ELECTRICAL
CITY
TATE
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ZIP
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FAX
( -7 C6 3 Z- �'ZI y
CONTRACTOR
WA STATE CONTRACTOR'S LICENSE # EXPIRATION DATE
WAsH r L io$ 45
FEDERAL WAY BUSINESS LICENSE #
10-0c,- O& - o0 GL
NAME
PRIMARY PHONE
APPLICANT
W A 5 k r ') (b u A Ari , M i
(� ) 3 L,5 - � 4s
MAILING ADDRESS
Zi). r Q0 r4 a f
E-MAIL
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CITY
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ST E
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ZIP
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FAX
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PROJECT CONTACT
NAME
PRIMARY PHONE
Ob) 436 - $
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 supp ty as apart of this application.
SIGNATURE / DATE ~/ 014 Z O LS
PRINT NAME: Tz t, S F(W c?vi 4—
Bulletin #160 - January 1, 2013 Page 1 of 2 k:\Handouts\Electrical Permit Application
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