15-104254CITY Of ....
Federal Way
RECEIVED
AUG 24 2015
CITY OF FEDERAL WAY
CDS
ELECTRICAL
PERMIT APPLICATION
PERMIT NUMBER 9 _ I O Y�5y _
SITE ADDRESS: ;k%16 .' ///L / % /tD
SUITE/UNIT/SPACE M
PROJECT VALUATION
$ �
ASSESSOR'S TAX/PARCEL 8
-0-L 1)" / -0 L - C/
CURRENT/PROPOSED USE
PROJECT NAME
(Tenant or Homeowner Last Name)
4 A
it/CrU oT/� �GA�T�w�/
r '«
PROJECT DESCRIPTION
Detailed description of work to
be included on this permit only
NAME
PRIMARY PHONE
PROPERTY OWNER4e-
-,v
( ) -
MAILING ADDRESS
E-MAIL
CITY
STATE
ZIP
FAX
( )
NAME
PRIMARY PHONE
MAILING ADDRESS
EMAIL
ELECTRICAL
/Ics,//—�4- 2i7 Al v/TCr - L
CITY
�i4C it �L
STATE
t. -J 1'1—
I ZIP
`I K46e/ `1
FAX
( ) -
CONTRACTOR
WA STATE CONTRACTOR'S LICENSE N EXPIRATION DATE
j—lrte' .54'iE 0STze--1 6,
FEDERAL WAY BUSINESS LICENSE M
NAME
PRIMARY PHONE
APPLICANT
Fllco ' SST 741 e. /!- ST
( ) -
MAILING ADDRESS
EMAIL
CITY
STATE
ZIP
FAX
( )
PROJECT CONTACT
NAMEPRIMARY
!>Z� �i��L��ti
PHONE
1(2 i'5 ) 9S/ - & S
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 Federal Way as to any claim (including costs, expenses, and attorneys' fees incurred in
the investigation and defense of such clai hich may be made by any person, including the undersigned, and filed against the city,
but only where such claim arises out ie reliance of the city, including its officers and employees, upon the accuracy of the
information supplied to the ity a p rt ft Is application. f
SIGNATURE: DATE �1 L/�S
PRINT NAME: f4dC V1 11
Bulletin #160—January 1. 2013 Page 1 of 2 k:\Handouts\Electrical Permit Application