14-1020904011
CITY OF 4
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Federal Way
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ELECTRICAL
PERMIT APPLION
PERMIT NUMBER 1-4 10 70 q (D �✓
MAY 0 7 2014
CITY OF FFnFReI IA/AV
SITE ADDRESS:J '•
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SUITE/UNITit
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PROJECT VALUATION
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CURRENT/PROPOSED USE
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PR ECT NAME
(Tenant or Homeowner Last Name)
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PROJECT DESCRIPTION
Detailed f work to o description
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be included on this permit only
PROPERTY OWNER
NAME
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PRIMARY PHONE
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MAILING /A�DDREESS C C
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MAIL >
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STATE
ZIP
FAX
NAMS,
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PRIMARY PHONE
MAILING A&RESS s,
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ELECTRICAL
IITY�
STATE
ZIP
FAX
CONTRACTOR
WA STAT ONTRACTOR'S LICENSE A EXPIRATION DATE
FEDERAL WAY BUSINESS LICENSE N
NAME _
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PRIMARY PHONE
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APPLICANT
MAILING ADDR SS
E-MAIL
CITY
STATE
ZIP
( FAX
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PROJECT CONTACT
N!t�J i
PRIMARY PHONE
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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 Iaws 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 thelgty, including its officers and employees, upon the accuracy of the
information supplied to the city as apart of this application./
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SIGNATURE: ,L/'i � DATE
PRINT NAME:
Bulletin #160 —January 1, 2013 Page 1 of 2 k:\Handouts\Electrical Permit Application