15-100232CITY OF A
Federal Way
WEIM ELECTRICAL
JAN 15 2015 PERMIT APPLICATION
f
ny OF FEDERAL WAY
PERMIT NUMBER �- _ 6- C 3 � _ tL
(SUITE/UNIT/SPACE
SITE ADDRESS: j 1 1 V
#
VALUATION
ASSESSOR'S TAR/PARCEL #
CURRENT/PROPOSED USE
PROJECT
(�
PROJECT NAME
n
(Tenant or Homeowner Last Name)
PROJECT DESCRIPTION
Detailed description of work to
be included on this permit only
PROPERTY OWNER
NAME 1
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PRIMARY PHONE
✓
M� ADDRESS
E-MAIL
/
Cf"'o A _ r , STATE ZIP .-.
M
NAW
FAX
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PRIMARY PHONE
MAILING ADDRESS ��
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E-MAIL
%V+01�-�VI�S Grn
ELECTRICAL
CONTRACTOR
CITY
STAT
ZIP
CI M 1
FAX
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WA STATE CONTRACTOR'S LICENSE # IONeDATE
FEDERAL WAY BUSINESS LICENSE #
PRIMARY PHONE
NAME
APPLICANT
MAILING ADDRESS
E-MAIL
CITY
STATE
ZD'
FAX
(
PROJECT CONTACT
NAME
I (?
P MARY PHONE
('Z S 01-1
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 cert(& 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 apart of this application.
SIGNATURE:
PRINT NAME:
Bulletin # 160 — January 1, 2013 Page 1 of 2 k:\Handouts\Electrical Permit Application
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