13-102232CITY OF `"
Federal Way
PERMIT NUMBER
ELECTRICAL
PERMIT APPLICATION
RECEIVE®
MAY 21 202
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SITE ADDRESS: Z �j SWj i �r
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PROJECT VALUATION
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CURRENT/ PROPOSED USE
PROJECT NAME
(Tenant or Homeowner Last Name)
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PROJECT DESCRIPTION
Detailed description of work to
be included on this permit only
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PROPERTY OWNER
NAME .. ,(� f
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PRIMARY PHONE
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MAILING ADDRESS n `
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E-MAIL
CITY
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STATEZIP
17d
FAX
ELECTRICAL
CONTRACTOR
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PRIMARY PHONE
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MAILING ADDRESS
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E-MAIL
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ZIP ��
FAX
WA STATE CONTRACTOR'S LICENSE N EXPIRATION DATE
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FEDERAL WAY BUSINESS LICENSE N
APPLICANT
NAME
PRIMARY PHONE
MAILING ADDRESSC,
2 ;'53
E-MAIL
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FAX
PROJECT CONTACT
NAME
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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 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 ay be made by any person, including the undersigned, and filed against the city,
but only where such Claim arises out of the reli nee j the city, including its officers and employees, upon th %accuracy of the
information supp to city as a part of trlis a pli tion.
SIGNATURE: DATE
PRINT NAME: CG `�Vl
Bulletin # 160 —January 1, 2013 Page 1 of 2 k:Wandouts\Electrical Permit Application