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CITY OF \\;,
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Federal Way Ffc7V'ydP
PERMIT APPLICATION rp
**Most electrical permits may be obtained on-line at www.cityoffederalway.com**
SITE ADDRESS: 3cgs/a 3„ , A y� S
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SUITE/UNIT/SPACE# ASSESSOR'S TAX/PARCEL# CURRENT/PROPOSED USE
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PROJECT NAME _ _
(Tenant or Homeowner Last Name) L—5- C�,,e,e/ejC# f, y,
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PROJECT DESCRIPTION /Ai -.5.44/4e. Caie�,IQ A.E,!/l e 2 i�--
Detailed description of work to
be included on this permit only 7)
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NAME PRIMARY PHONE
PROPERTY OWNER .3,2/.25 No,er/i 444 - (.0253) cf 22-- 9,70
MAILING ADDRESS E-MAIL
CITY STATE ZIP FAX
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NAME PRIMARY PHONE
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MAILING ADDRESS' E-MAIL
BitECTIMAL PIP 5/ 1"itirlecid ,4t -5;2- 5k7' - /1,7 ,? 64'0,1 �y?i v c
CONTRACTOR CITY STATE ZIP , X
i .t✓�10 14).01 ,��o.S7 (7sl FA),51-Pei y
WA STATE CONTRACTOR'S LICENSE# EXPIRATION DATE FEDERAL WAY BUSINESS LICENSE#
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NAME PRIMARY PHONE
APPLICANT .1/free Ars Adai/G (evy✓lire',,%'1',!) ( ) -
MAILING ADDRESS / E-MAIL
CITY STATE ZIP FAX
( ) -
NAME �" .,,,j PRIMARY PHONE
PROJECT CONTACT 9% 514.1//I'
(0353)73A -,.5-72.,„.z.
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 DATE �l2 .%1
PRINT NAME: ` CJ`e
33325 8'"Avenue South♦Federal Way 1 WA♦98003-6325♦253-835-2607♦fax 253-835-2609 1 www.cityoffederalway.com
Bulletin#160—January 1,2011 Page 1 of 2 k:AHandouts\Electrical Permit Application