14-101414 scam°
A.
CITY OF .ti.> .�.� ELCTRICAL
MAR 2 8 2014
Federal Way PERMIT APPLICATION
CITY OF
ED RAL WAY
•PERMIT NUMBER / 7 _ / V ( ( y-
SUITE/UNIT/SPACE#
SITE ADDRESS: 3;2155 1 ' A ye-e `== vim J
PROJECT VALUATIONASSESSOR'S TAX/PARCEL# CURRENT/PROPOSED USE
$ 350 8 ) ( Y _ 9 O 3 7
PROJECT NAME —7 .__ a_t)q
(Tenant or Homeowner Last Name) `
9 k ciaza../.,k-, a.../....s:LS
PROJECT DESCRIPTION
Detailed description of work to
be included on this permit only
NAME • PRIMARY PHONE
PROPERTY OWNER -7— l 1 ti ,7 a- (--( ( ) -
MAILING ADDRESS E-MAIL
J ) � 14- f 1 ✓'e J .
J
CITY STATE ZIP ( FAX
)
NAMEp II ,, 11 PRIMARY PHONE
951 3 K, U Jg `T-eC(i r1U\Cx) 'e S { ) 22 I - 42_0-3MAILING ADDRESS / t E-MAIL
ELECTRICAL (LQct ry, `i r � 1 C.- 1 ��e we5f�i-echrulmPres.Com,
CONTRACTOR r•-•13.-0.0--
�•�j� Z n• ��� FAX
WARACTOR'S LICENSE# (.�J EXPIRATION DATE FEDERAL WAY BUSINESS LICENSE#
SXR UI gq.C) fl'1.7 Fs' ( / 1
NAME C ( n C p ^^ PRIMARY PHONE
cllA
APPLICANT -MAILING ADDRESS ` ir,1 V i ( ) E-MAIL
CITY STATE ZIP (/ FAX
( ) -
NAME �� PRIMARY PHONE
PROJECT CONTACT -<)p { c A-'r & P;3) 221- `f 2O
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 reli•• - of ' , includin officers and employees, upon the accuracy of the
information supplied to the city as a p• - Ts ••• i on.
SIGNATURE: - - t DATE 5`2 `- 7L..)
PRINT NAME: 1 OD A •
Bulletin#160—January 1,2013 Page 1 of 2 k:\Handouts\Electrical Permit Application