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City of Federal Way
33530 First Way South
Federal Way, WA 98003-6210
$
(253)661-4000
APPLICATION FOR MECHANICAL PERMIT
PARCEL Single Family 0 Multi -Family 13 Commercial
Tenant/Owner: Phone:
Address/City/State/Zip:
Nature of work: — L� ja C_ i Project Valuation: $
APPLICANT::.,
Address/City/St/Zip: Z&Z-2..
64L&I Phone:
Contact Person: 06_62---�E - Fax: 3_LZ5__
Company Name:
Address/City/St/Zip:
Contact Person: —Phone: Fax:
State L & I Contractor Registration #: Exp. Date:
(Card must be presented)
MECHANICAL UNIT COUNT:
DISCLAIMER: I certify under penalty of perjury that the information furnished by me is true and correct to the best of my knowledge and further that I am authorized by the owner of the above
premises to perform the work for which permit application Is made. I further agree to save harmless the City of Federal Way 20 to any dalm (including costs, expenses and attorneys' few incurred
in investigation and defer= of such claim), which may be made by any person, Including the undersigned, and filed against the City of Feclaray Way but only where such claim wises out of the
reliance of the City, including its officers and employees, upon the accuracy of the information supplied to the City as a pan of this application.
Owner/Agent: Date—L—L&L-41-7