14-106032CITY OF 'A
Federal Way
ELECTRICAL
PERMIT APPLICATION
PERMIT NUMBER `� _ � � � D �L/_ 00
NOV 20 2014
—T .� 1 1 I M
SITE ADDRESS:
3qqOS14o\,�S
S P CDS
PROJECT VALUATION
ASSESSQW TAR/PARCEL#
3 0 t
20
CURRENT/PROPOSED USE
$ 5501=
-q-
0 3
PROJECT NAME
1
"1
1
Tenant or Homeowner Last Name 1
`1
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PROJECT DESCRIPTION
Detailed description of work to
be included on this permit only
NAME
PRIMARY PHONE
PROPERTY OWNER
OO l
c "
MAILING ADDRESS
11AA
01 AJEC
WMAIL
CITY
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STATE
ZIP
q 232
FAX
((% -
NAME
A
%hc
PRIMARY PHONE
c 206 S- 3 28 5
MAILIN ` _•
S Air
EMAIL
ELECTRICAL
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7.
CI
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STATE
W
ZIP
PC,6(-5L4
FAX
c V 77,M
CONTRACTOR
W STATE CONTRACTOR'S LICENSE #
3
EXPIRATION DATE
2
FEDERAL WAY BUSINESS LICENSE #
.00• (A2 -oo
NAMEC
PRIMARY PHONE
C
APPLICANT
MAILING ADDRESS
E-MAII.
CITY
STATE
ZIP
FAX
PROJECT CONTACT
NAME
-n
PRIMARY PHONE
4 ?J gK
( )32C -
I certify under penalty of perjury that I am the property owner or authorized agent of the property owner. 1 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 claimf, 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 a part of this application. �j�
SIGNATURE: i!;/� !�_2ir— DATE G(/' 190/Y
PRINT NAME:
Bulletin #160 — January 1, 2013
Page 1 of 2
k:\Handouts\Electrical Permit Application
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