19-101973RECEIVED
CITY OF �> "�-ti=�"'
Federal Way APR 2019
25
ELECTRICAL
PERMIT APPLICATION
Gl7Y OF FEDERAL Wf1Y ERMIT NUMBER _
CafV}�+IUNrFY QEYELDPM�>, I — --_ — —
SUITE/UNIT/SPACE #
d
SITE ADDRESS: 2 al -+Z 6 p L
PROJECT VALUATION ASSESSOR'S TAX/PARCEL # CURRENT/PROPOSED USE
PROJECT NAME
(Tenant or Homeowner Last Name) ma �4 r k,c e !
PROJECT DESCRIPTION
Detailed description of work to
be included on this permit only
NAME
PRIMARY PHONE
PROPERTY OWNER
(2®6 )q_jo - 7 223
MAILING ADDRESS
E-MAIL
CITY
3 E
ZIP
FAX
ME
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PRIMARY PHONE
(Zvi) -774' -11 q/
ELECTRICAL
G ADDRES
tt '( 1 4L-t h f� V
E-MAIL
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CI
STATE
ZIP
9000 Le 2-
FAX
CONTRACTOR
WA STATE CONTRACTOR'S LICENSE # EXPIRATION DATE
FEDERAL WAY BUSINESS LICENSE #
0 n-1 e e 7f 8 ;V61 o7 120 zp
- —
- - - — -
NAME Q m L W (Q C� ✓F C
PRIMARY PHONE
" a,`C ` "'"` t,cx
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APPLICANT
MAILING ADDRESS
E-MAIL
CITY STATE I ZIP
NAME
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FAX
PRIMARY PHONE
(W6 ) 77,e- / 1 q 1Y
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 to the city as a part of this application.
SIGNATURE:
DATE
PRINT NAME: Q
Bulletin # 160 — April 14, 2016 Page 1 of 1 k:\Handouts\Electrical Permit Application