13-102015CITY OF ._....
...........
Federal Way
PERMIT NUMBER ( 3
ELEC'T'RICAL
PERMIT ApEP,�J%TION
2 0 1 5
OC) MAY 0 8 2013
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SITE ADDRESS: .� y � ?J .� f � � �/� � (,�;/
SUMLUNIT/SPACE #
J
PROJECT�DATION
ASSESSOR'S TAX/PARCEL # � O_ O � � �
CURRENT/ PROPOSED USE
PROJECT NAME
(Tenant or Homeowner Last Name)
e
PROJECT DESCRIPTION
Detailed description of work to
be included on this permit only
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PROPERTY OWNER
NAME /
l� U L d� U SS t n q (�
PRIMARY PHONE
(Z'53) Z5 L- 7 -
MAILING
MAILINGG A�DDDRESS [�^{ / � � �
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E-MAIL
CITY
STATE
ZIP
FAX
ELECTRICAL
CONTRACTOR
NAME-
PRIMARY PHONE
MAILING ADDRESS I
r L �14 cc S'
E-MAIL
CITY
STATE
ZIPS,,
FAX
WA STATE CONTRACTOR'S LICENSE M EXPIRATION DATE
FEDERAL WAY BUSINESS LICENSE R
APPLICANT
NAME
C-0 en
PRIMARY PHONE
MAILING ADDRESS
E-MAIL
CITY
STATE
ZIP
FAX
PROJECT CONTACT
NAME
ill SSS Al 9 C: le 12Z S , We1" t-
PRIMARY PHONE
( ) _
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 Iocal, 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 apart of this application.
SIGNATURE:
PRINT NAME:
TE A
Bulletin # 160 — January 1, 2013 Page 1 of 2 k:AHa-ndouts\Electrical Permit Application