19-104562 (2)CITY OF
Federal Way
RECEIVED ELECTRICAL
SEP 23 2019 PERMIT APPLICATION
CiTY OF FEDERAL WAY
COMMUNITY DEVELOPMENT
PERMIT NUMBER l _
1 0 L(s G Z_ O 0
SUITE/UNIT/SPACE #
SITE ADDRESS: ZI07
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PROJECT VALUATION
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ASSESSOR'S TAX/PARCEL # /'�
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CURRENT/PROPOSED USE
PROJECT NAME
(Tenant or Homeowner Last Name)
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PROJECT DESCRIPTION
Detailed description of work to
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be included on this permit only
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PROPERTY OWNER
NAME I., W
PRIMARY PHONE
(2C4F WC I
MAILING ADDRESS
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CITY l�� �
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ZIP {
NAME
PRIMARY PHONE
MAILING ADDRESS
E-MAIL
ELECTRICAL
CITY STATE
ZIP
FAX
CONTRACTOR
WA STATE CONTRACTOR'S LICENSE # EXPIRATION DATE
FEDERAL WAY BUSINESS LICENSE #
NAME
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APPLICANT
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MAILING ADDRBS ` ,�� !
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E-MAIL
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ZIP
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PROJECT CONTACT
NAME �J
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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 to the city as apart of this application.
SIGNATURE:
PRINT NAME:
DATE f; I
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Bulletin # 160 — April 14, 2016 Page 1 of 1 Ul-landouts0ectrical Permit Application
RECEIVED
I �— ► og3-1� 2
SEP 2 3 2019
'lly ~� _ Property Owner
CC3MMtlN�y � �RA1_ WAY
Federal Way EiectrlcaEYW6k Permit Application
Applying For Your Electrical Permit ` %F
In Washington, only licensed electrical contractors may perform electrical work. Property owners
may apply for an exemption from these requirements by completing this application and signing
the affidavit below before beginning electrical work.
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A 'davit
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As authorized under RCW 19.28.261, I 64 1 04-Q i. hereby apply
(Printed na (e ofproperty owner, renter, or lessee)
for an exemption from the electrical licensing and certification requirements of RCW 19.28 by
submission of this affidavit.
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Which stateincut describes you? (Mctrk only one. Lf. none apply. you may not take our [leis perry:idIV .)
I own this property._ -:--•_--_--
Your name or your company's name must be shown on the deed to the property. Real estate agents' property
management companies, relatives, etc. cannot purchase permits for the property owner.
❑ I rent or lease this property.
We need a copy ofyour rental agreement showingyou have permission to perform electrical work.
❑ I am an officer for a 501(c)(3) nonprofit corporation, or a nonprofit religious organization. .
The total market value of electrical work must be $30, 000 or less and all electrical work tnusl be done by a
non -compensated appropriately certified electrician.
1
Select you r property type (Mark only. one. If none apply, you may not takeout this jwrmit)
❑ New single family residence that is not intended for rent, sale, or lease, where I will be livingfor]
at least 24 months after completing the electrical work. I will be personally doing the electrical
work.
I
❑ New 2, 3, or 4 unit residential building, owned by me, that is intended for rent, sale, or lease. I
will be living in one of the units for at least 24 months after completing electrical work. 1,
1 personally, and/or a regularly employed employee(s), will be doing the electricalwork.
1 ❑ New place of business, farm, or other property: Any new structure that is not intended for rent, a
sale, or lease. 1, personally, and/or a regularly employed employee(s), will be doing the electrical work.
Existing residential property, place of business, or farm. I, personally, and/or a regularly
employed employee(s), will be doing the electrical work.
DEPARTMENT OF COMMUNITY DEVELOPMENT / 33325 8TH AVENUE SOUTH / FEDERAL WAY, WA 98003-6325
253-835-2607 � www.cltyoflpderalway.com -s oermitcente citYoilederalway-com
Bulletin 4080 - June 6, 2018 Page 1 of 2 k:\Handoutsl Property Owner Electrical Work Application
❑ 501(c)(3) or nonprofit religious organization owned property: The total market value of the
electrical work must be $30,000 or less, and all electrical work will be performed by appropriately
certified electricians, or certified and properly supervised trainees, who are volunteering and not
being compensated for the electrical work per RCW 19.2&091(7).
Your signature is required belovv:
I believe I should be exempt from the requirements to obtain an electrical license, or use a certified c
electrician, as provided under RCW 19.28.261. it
By signing below, I certify the information I am providing on this affidavit is true and accurate. I
understand that if I make false statements or misrepresentations, I may be assessed penalties.
P-int'ed Name of Property Owner, Renter, or Lessee S' Mature
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Date
- -Property Owner and -Inspection Site -Information __--
Property Owner's Name (Last, first) or Company Name v
Mailing Address Unit/Apt.# City State Zip
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Daytime Phone Email Address
Inspection Site Address (if different) Unit/Apt.# City State Zip
County Electrical Power Company /Serving Utility
Description of work being Clone (Example: adding outlets in the kitchen. second floor bmak area: etc.)
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Add 1?iGtiJ Ol t•Alt s /on wc4tef t Ra-k..
DEPARTMENT OF COMMUNITY DEVELOPMENT / 33325 8T" AVENUE SOUTH / FEDERAL WAY, WA 98003-6325
253-835-2607 -9 w w cit ❑ffederalway.cam As ermitcenter cit offederalwa -com
Bulletin 4080 — June 6, 2018 Page 2 of 2 k:\Handouts\ Property Owner Electrical Work Application