16-105222RECEIVE®
ciTY of
Federal Way OCT 2 s 2016
CITY OF FEDERAL WAY
CDS
ELECTRICAL
PERMIT APPLICATION
PERMIT NUMBER I (/ 10 S ? ? 2,_ ou
��
SITE ADDRESS: 3'4-7 9 6 Ave S
SUITE/UNIT/SPACE#
PROJECT VALUATI
$ -7bo ,co ��
ASSESSOR'S TAR/PARCEL
CURRENT/PROPOSED USE
PROJECT NAME
(Tenant or Homeowner Last Name)
�V e r r
L
PROJECT DESCRIPTION
Detailed description of work to
be included on this permit only
n
F YZ� ALAYZ vvt "r"`
p% u
PROPERTY OWNER
NAME_ __ PRIMARY PHONE
Z. Q r ('r.ers_ 2 ayt4lr (R�lq 3yo 3S9S'
MAILING ADDRESS E-MAIL
3Lf7ta �k AvE S
r VV61
STATE
VvJ
ZIP FAX
g5o0 3 (ZO6) Z I Z• 21 7
ELECTRICAL
CONTRACTOR
NAME 9PRIMARY
A laevo
PHONE
P53 ) 7 Sq- 7 /6
MAILING ADDRESS o(Ala r a �� E-MAIL
TSU bq 9 �"A (`"
CITYY
WovhA-
STATE
WA
ZIP FAX
q / 53)YN- I37b
WA ST TE CONTRACTOR'S LICENSE # EXPIRATION DATE FEDERAL WAY BUSINESS LICENSE #
MAZMS'508 (9 VJ 10 IZ Z i I 20-02-100613-00-131
APPLICANT
NAME
PRIMARY PHONE
MAILING ADDRESS
E-MAIL
CITY
STATE
ZIP (
l
FAX
)
PROJECT CONTACT
NAM h { rI r 1
1 S
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 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 as part of this application. it
SIGNATURE: �+1 /,..L— DATE 16- Z e -
PRINT NAME: C k r -c r f4c F*_
Bulletin # 160 —April 14, 2016 Page 1 of 1 k:\Handouts\Electrical Permit Application
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