16-103030CITY OF
Federal Way
RECEIVED ELEC'T'RICAL
JUN 2 2 2016 PERMIT APPLICATION
CITY OF FEDERAL WAY
CDS PERMIT NUMBER
SITE ADDRESS: �� � � .,,
1 s, T
SUITE/UNIT/SPACE #
,., ,
6 z� -
PROJECT VALUATION
$I�7z`/d, 00
ASSESSOR'S TAX/PARCEL #
J _n) -0 C-) - COAD
CURRENT/PROPOSED USE
PROJECT NAME
(Tenant or Homeowner Last Name)
PROJECT DESCRIPTION
Detailed description of work to
be included on this permit only
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PROPERTY OWNER
NAME
1-1rQ I
PRIMARY PHONE
_
MAILING ADDRESS
E-MAIL
CITY
STATE
ZIP
FAX
)
Z Z 4 0 6�
ELECTRICAL
CONTRACTOR
NAME
� C !ST-
PRIMARY PHONE
NZ -5)-315- 5G75
MAILING ADDRESS
d t q Z�/ q
E-MAIL
KA 4(d 0216,04
CITY
STATE
lam'
ZIP
o r z—
FAX
c Itz5) 4� � (-
WA STATE CONTRACTOR'S LICENSE # EEXPI/RATION DATE
{/'
ZZ 1)7
FEDERAL WAY BUSINESS LICENSE #
APPLICANT
NAM ;
PRIMARY PHONE
MAILING ADDRESS
E-MAIL
CITY
STATE
ZIP
PROJECT CONTACT
NAME
PRIMARY PHONE �'-
I certify under penalty of per ury that I am the property owner or authorized agent of the property owner. I cer?ify�hat to the best
Of my knowledge, the information submitted in support of this permit application is true and correct. I certify that I wilfromply-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 Iaws.
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 of and employees, upon the accuracy of the
information supplied to the city as q part of this application.
SIGNATURE:
PRINT NAME:
Bulletin # 160 —April 14, 2016 Page 1 of 1 k:\Handouts\Electrical Permit Application
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