14-105736` NOV 0 4 2014
CITY of CITY OF FEDERALWAY ELEC'T'RICAL
Federal Way CDS I PERMIT APPLICATION
PERMrr NUMBER l _ V S- 3&_00 00
. �10ci Sw MP
ADDRESS. `�-s7
3UITE/UNIT/SPACEiSITE
PROJECT VALAAT N
$ 1114-
ASSESSOR' T/1x�PAR�EL i ^
03, 6?—
CURRENT/ POSED USE
5;0
_
PROJECT NAME—
(Tenant or Homeowner Last Name
�(
,J L _ (
PROJECT DESCRIPTION
Detailed description of work to
be included on this permit only
PROPERTY OWNER
NAME
P - 1i(ZS3
PRIMARY PHONE
► s1 - 8
MAH.ING ADDRESS
3►a1�
E-MAIL
sw 3LIHt—t' s
CITY p
STATE
ZIP
FAX
NAME
PRIMARY PHONE
ELECTRICAL
MAILING ADDRESS
q6 LtS �- F
E-MAIL
CONTRACTOR
CITY
STATE
ZIP
FAX
K
w
U 03
( ) -
WA STATE CONTRACTOR'S LICENSE ♦ EXPIRATION DATE
FEDERAL WAY BUSINESS LICENSE #
M1 Zit i1`7
NAME
PRIMARY PHONE
APPLICANT
( )
MAILING ADDRESS
E-MAIL
CITY
STATE
ZIP
FAX
()PRIMARY
PROJECT CONTACT
NAME
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 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 th jW application.
SIGNATURE:
PRINT NAME:
Bulletin # 160 —January 1, 2013 Pagel of 2 k:\Handouts\Electrical Permit Application