16-100042CITY OF
Federal Way
RECEIVED
JAN 0 5 2016
CITY OF FEDERAL. WAY
CDS
ELECTRICAL
PERMIT APPLICATION
PERMIT NUMBER I �0 _ 10 0 C) 1 2– et -
SITE ADDRESS: 1 860 S 336TH ST., FEDERAL WAY WA 98023
BUTTE/UNIT/SPACE #
PROJECT VALUATION
ASSESSOR'S TAR/PARCEL #
CURRENT/PROPOSED USE
5,000
0 4 1 9 0 3- 0 2 6
CHURCH
PROJECT NAME
(Tenant or Homeowner Last Name)
RUSSIAN UKRANIAN PAROUSIA SDA CHURCH
TO BRING ELECTRICAL POWER ON J BOX AT THE CORNER OF
20TH & 336TH TO THE NEW STREET LIGHT ON 20TH BY
PROJECT DESCRIPTION
PARKING LOT ENTRANCE.
Detailed description of work to
be included on this permit only
NAME
PRIMARY PHONE
PROPERTY OWNER
WASHINGTION CORP. OF SDA
( 25) 681-6008
MAIIJNO ADDRESS
E-MAII.
32229 WEYERHAEUSER WAY S
CITY
STATE
ZIP
FAX
FEDERAL WAY
WA
I
98001
I
NAME
PRIMARY PHONE
TRIPLE TREE ELECTRIC, INC.
(360 580-3641
MAILING ADDRESS
198 BRADY LOOP RD E
E-MAIL
fttratie&4('GE
ELECTRICAL
CITY
STATE
ZIP
FAX
CONTRACTOR
MONTESANO
WA
I
98563
I
WA STATE CONTRACTOR'S LICENSE # EXPIRATION DATE
FEDERAL WAY BUSUHM LICENSE #
TRIPLTE891QG
NAME
PRIMARY PHONE
APPLICANT
KIRKMAN ASSOCIATES LLC
(253 )833 -7910
MAILING ADDRESS
E-MAIL
PQ BOX 816
CITY
AUBURN
8TATE
WA
ZIP
98071
FAX
PROJECT CONTACT
NAME
DON KIRKMAN
PRIMARY 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 work 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
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