14-103116Cffy of A
Federal Way
PERMIT NUMB= il
JUN 2 6 2014
CITY OF FEDERAL WA ELECTRICAL
CDS PERMIT APPLICATION
SITE ADDRESS: 35-703 % b 4 k A V-(, ,S
.
SUITE/DIMIT/SPACE i
L tit
PROJECT VALUATION
�TAX/PAR } O
1
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CiIRREIIT/PROPOSED USE;
000.00
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/ _
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PROJECT NAME
qIJ` A
(Tenant or Homeowner Last Name)
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PROJECT DESCRIPTION
.
Detailed description of work to
be included on this permit only
PROPERTY OWNER
NAM
C"-
PRIMARY PHONs
MAILIIIG ADDRRSS
gMAI,
120
CITY
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STATE
ZR
Woo
FAX
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PRIMARY PHORE
( -
JEAMUIG ADDRESS
E KA+•
ELECTRICAL
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L?
CONTRACTOR
crry
SATE
WA
21P
9
FAX
WA STATE CONTRACTOR'S LICENSE #
69 15 d ^ �,�3
EXPIRATION DATE
�9 i 16
FEDERAL WAY RDBDa les LICENSE #
0
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HONE
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APPLICANT
1IAU D(G ADDRESS
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sk. su. � Z� d
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CITYSTATE
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ZIP
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TAX
PROJECT CONTACT
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PRIMARY PHONE 3
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Z cerWy under penalty of perjury that I am the property owner a
of my knowledge, the information submitted in support of this perm
all applicable City of Federal Way regulations pertaining to the wa
issuance of this permit does not remove the owner's responsibill
construction or environmental laws.
I further agree to hold harmless the City ai Federal Way as to an
the investigation and defense of such claim), which may be made by
but only where such claim arises out of the reliance of the city,
irtformation supplied to the city as a part of this application.
SIGNATURE:
PRINT NAME:
authorised agent of the property owner. Z certify that to the best
t application is true and correct Z certify that Z will comply with
k authorised by the issuance of a permit Z understand that the
y for compliance with local, state, or federal laws regulating
claim (including cost , saeperaaes, and attorneys' j i.— d t-
iny person, including the undersigned, and filed against the city,
ncluding its officers and employees, upon the accuracy of the
Bulletin #160 —January 1, 2013 Page l of I k:\Handouts\Electrical Permit Application
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