18-103868 (2)Co" of A
Federal Way
RECEIVED
AUG 22 a$ ELECTRICAL
n& EW,Mr PERMIT APPLICATION
PERMIT NUMBER 19 _ I 0 �3 6-68— 00
SITE ADDRESS: 2 v3l q +� r 5
SUITE/UNIT/SPACE #
�J f�J
PROJECT VALUATION
ASSESSOR'S TAR/PARCEL #
CURRENT/PROPOSED USE
jp�
U
�
—
PR CT NAME
(Tenant or Homeoumer Last Name)
►w
�'� fJ/ C Uta, �� 9,h s
�] 8. T
K l
PROJECT DESCRIPTION
Detailed description of work to
be included on this permit only
A1168
PRIMARY PHONE
PROPERTY OWNER
�, c� u J
03),913 - /119
MAILING ADDRESS
µ T S,
E-MAIL
on✓ vt1' P-J LOP
CITY
STATE ZIP
FAR
g
( )alm
N
PRIMARY PHONE
t� YL � 4)
j�
L
MAILING ADDRESS
a H s•
E-MAIL
ELECTRICAL
q
1
crrY
STATE
ZIP
%�0 D 3
FAX
CONTRACTOR
F-dE, Uj
e4-
) n
WA BTA7`P 6 LICENSE # EXPIRATION DATE
FEDERAL WAY BUSINESS LICENSE #
S DOS �_�° /4 --_
—
-
PHONE
P23 Y
�m � c .1P�
(53) l'V z�
APPLICANT
AIAI .G ADDRESS
�,�
E-MAIL
3 e-T,
CITY
BTA E
ZIP
r FAX
yy
nekl
N
PRIMARY PHONE
PROJECT CONTACT
0 y"I t
I certify under penalty ofperjury that I am the property owner or authorised 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 nark authorised 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 ity as apart of this application.
SIGNATURE: f1DATE
PRINT NAME: LJA Y1 ULJ IDS
Bulletin #160 —April 14, 2016
PERMIT CENTER + 33325 81h Avenue South + Federal Way; WA 98003-6325
253-835-2607 + FAX 253-835-2609 + pe—itcenter a:cityoffedera]way
Page 1 of 1
k:\Handouts\Electrical Permit Application