16-104457CITY OF
Federal Way
RECEIVED
SEP 08 2016
CITY OF FEDERAL WAY
ELEC'T'RICAL
PERMIT APPLICATION
CDS %
PERMIT NUMBER i O _ I O q q 5� _ lj
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 investigationan defense of such claim), which may be made by any person, including the undersigned, and filed against the city,
but only where su claim arises out of the reliance of the city, including its officers and employees, upon the accuracy of the
information suppli to the city as a part of this application.
SIGNATURE: DATE 9/6/2016
PRINT NAME: ary Lerdahl, President
PERMIT CENTER + 33325 811, Avenue South + Federal Way, WA 98003-6325
253-835-2607 + FAX 253-835-2609 + permitcentel acityoffederalway.com
Bulletin #160 —April 14, 2016 Page 1 of 1 k:\Handouts\Electrical Permit Application
SUITE/UNIT/SPACE#
SITE ADDRESS: 1530 S DASH POINT RD FEDERAL WAY, WA 98003
PROJECT VALUATION
ASSESSOR'S TAR/PARCEL #
CURRENT/PROPOSED USE
$ 7,500.00
NA _
PROJECT NAME
(Tenant or Homeowner Last Name)
Sacajawea Middle School SRTS
Site located at SW corner of 16th Ave S and Dash Point Rd
Installation of new service.
PROJECT DESCRIPTION
Detailed description of work to
be included on this permit only
NAME
PRIMARY PHONE .
PROPERTY OWNER
City of Federal Way / Public Works
( 253) 835 - 2723
MAILING ADDRESS
E-MAIL
PO BOX 9718
CITY
STATE
ZIP
FAX
Federal Way
WA
98063-9718
( ) -
NAME
PRIMARY PHONE
DBE ELECTRIC INC
( 253) 887 - 8089
MAILING ADDRESS
E-MAIL
ELECTRICAL
PO BOX 9169
MARY@DBEELECTRICINC.COM
CONTRACTOR
CITY
STATE
ZIP
FAX
COVINGTON
WA
98042
( 253) 804 - 6066
LIG It
1
WA STATE CONTRACTOR'S LICENSE # EXPIRATION DATE
FEDERAL WAY BUSINESS LICENSE #
DBEELE19127M 11/ 6 / 2017
20 -16 -104173 -00 -BL
NAME
PRIMARY PHONE
APPLICANT
DBE ELECTRIC INC
( 253 ) 887 - 8089
MAILING ADDRESS
E-MAIL
^^
li 1
PO BOX 9169
MARY@DBEELECTRICINC.COM
CITY
STATE
ZIP
FAX
COVINGTON
WA
98042
( 253) 804 - 6066
PROJECT CONTACT
NAME
PRIMARY 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 investigationan defense of such claim), which may be made by any person, including the undersigned, and filed against the city,
but only where su claim arises out of the reliance of the city, including its officers and employees, upon the accuracy of the
information suppli to the city as a part of this application.
SIGNATURE: DATE 9/6/2016
PRINT NAME: ary Lerdahl, President
PERMIT CENTER + 33325 811, Avenue South + Federal Way, WA 98003-6325
253-835-2607 + FAX 253-835-2609 + permitcentel acityoffederalway.com
Bulletin #160 —April 14, 2016 Page 1 of 1 k:\Handouts\Electrical Permit Application