14-1040598^
RECEIVE --,
13 _
pp ELECTRICAL
CITY OF � t. f ; .l [ 014
Federal Way CMOF FEDERAL WAY PERMIT APPLICATION
t CDS
PERMIT NUMBER _1Y _ i —o o s i _ E L
SUITE/UNIT/SPACE #
SITE ADDRESS: r''�
PROJECT VALUATION
$ 357
ASSESSOR'S TAX/PARCEL # CURRENT/PROPOSED USE
1) () � ( )
PROJECT NAME
(Tenant or Homeowner Last Name)
j� j
C (l n t"
PROJECT DESCRIPTION
I v' c f�c c T c� (a c v ( rl
Detailed description of work to
be included on this permit only
PROPERTY OWNER
NAME
f�c1Cf C�t� : I , O (�
PRIMARY PHONE
OS ) Ns - �ZuoU
MAILING ADDRESS
33330
E-MAIL
Co M c :> ,) N,.(
CITY
{
STATE
ZIP
AX -
NAME
E Z Cil l C L
PRIMARY PHONE
(ass ) - &L( - 37v`7
MAILING ADD**SS
Q C> dX �� 3 102 i
E-MAIL
ELECTRICAL
CITY
L42
STATE
ZIP
37 3
AX
P2 d�q )
CONTRACTOR
WA STAT CONTRACOOR'S LICENSE # EXPIRATION DATE
C 5 c A S L"163 E V,
FEDERAL WAY BUSINESS LICENSE M
U, - 6,SS) - j(D
APPLICANT
NAME (( t r
PRIMARY PHONE
-
MAILING ADDRESS
E-MAIL
CITY
STATE
ZIP
FAX
(
PROJECT CONTACT
NAME
rl L, -Ac
PRIMARY PHONE
(a5,3 a&L� - 3 ?c),-7
I certify under penalty of perfury that I am the property owner or authorized agent of the property owner. I cert#%y that to the best
of my knowledge, the Information submitted in support of this permit application is true and correct. I certgy 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 Iaws 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
,edatm aes out of the reliance of the city, including its officers and employees, upon the accuracy of the
information supplieKtq/thAci a,�ji zrt of this application.
SIGNATURE:
PRINT NAME:
Bulletin #160 —January 1, 2013 Page I of 2 k:\Handouts\Electrical Permit Application
C -6A