15-105274CITY Of V&
Federal Way
RECEIVED
OCT 15 2015
CITY OF FEDERAL WAY
CDS
ELECTRICAL
PERMIT APPLICATION
PERMff NUMBM I s_1 d s a14_ (c_ L
SITE ADDRESS: f 15 j � 2¢'W- 4015 _5, �� � �� U�
S 0,vs1 TE #
PROJECT VALUATION
ASSESSOR'S TAX/PARCEL #
CURRENT/PROPOSED USE
PROJECT NAME
(Tenant or Homeowner Last Name)
—
r--
t AlAk24
PROJECT DESCRIPTION
Detailed description of uAork to
be included on this permit only
i
PROPERTY OWNER
NA>�4
U`� C l
PRIMARY
(r?b�) �� -'Hoz
(�
MAILING ADDRESS /
A)
EMAIL
CITY y/s�-�r`I/ �Oj �' A /S�T�A7TE ZIP
FAX
NAME op
F715i
03 L
MAILrnG ADDRESS
2 A 0 i�- 5S7,
EMAIL
d Frit
ELECTRICAL
CONTRACTOR
crrYSTATE
zIP
qeo
FAX
WA STATE CONTRACTOR'S LICENSE # EXPIRATION DATE
4 16,
FEDERAL WAY BUSINESS LICENSE #
NAME
PRIMARY PHONE
APPLICANT-
MAnrnG ADDRESS � � �
FIKAIL
CITY
t 00.0
STATE
ZIP
FAX
-
PROJECT CONTACT
NAME(
PAM �. j�
�) PRDIARY PHONE
I certify under penalty of perjury that I am the property owner or authorised 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 wo, k authorised 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 a part of this application.
SIGNATURE:
PRINT NAME:
Bulletin #160 —January 1, 2013 Page 1 of 2 k:\Handouts\Electrical Permit Application