13-100896 02/24/2013 21 50 #1992 P 001/001
•CEIVED •
FEB 2 6 2013 ELECTRICAL
CITY Of 11111//11A'
Federal Way CjN OF FEDERAL WAY PERMIT APPLICATION
CDS
PERaIT NOM 13 _ ) n 0 S 9 (P , 00 Devi-
02
_ _
SITE ADDRESS: evlre/vxrr/Spec$r
32
PROJECT VALUA'riox Alle tawOR'B TAX/PAR 4 Y CU'RRzNT/PROPOBtp USE
$ 6 it , 'e--- Z l 5 , S - 3O CdMi, il2CI
PRA ' CT NAME F����
/Tenant or Homeowner Last Name) £r C f_4 /t J
CtL� � ..., CO 1° a 60#4/i . . .
PROJECT DESCRIPTION 22 is /L o --e l r-lar —
Detailed description of work to (1�r-t. J �y�f-,� O
be included on thus permit only � �� r u L-�(1
NA= _ - p PRIMARY PRONE
PROPERTY OWNER FCitJ i L •
wO Vi T C A/! E (.2r,,3) 3c3-po
MAtWxOAMMAN tittAa,
3.202o 3y sv J # /Jo
CITY STATE SIP
ffJ9 it-Of L Gu4j' w4 9,60 I ( ) rex
NAPE PRIMARY PHONE
F 04 f4ar t At7tike' ('I.2-s' ) ,29?-2.14/
MAILIYO AnDREfO
ELECTRICAL PLO 8# /'t f
CONTRACTOR aITY STAT// w its-It
�f/£11�1� GUS 74206 (YX ).SZ - )-(-IS9
WA 5TATIt C Iy'taAGIORT LICSW=I 1CIPIRAPtolli PAFt 1lDERAL WAY SQSDILiie LICENCE I
NAIRIC PRl7UARY PROM
APPLICANT a-o C 0/1.340)(42_ i'"r ).731 - %c
MAILAni ADDRESS 6YADr
P/0 t vV 99 riC 01-1/440244.-0/41060(441
CITY UTATI ili5folv PAR
04t
NAME PROtARY PROM
PROJECT CONTACT 1D Y' I £ t'/ *4-0
( 25- 1 A31
Aa 7...5-
I certify under penalty of per}µry that I ant the property owner or authorised agent of the properly owner.I cernly that to the boat
of my knowledge,the information submitted in support of this parade application is true and correct.I certify that I will comply with
all applicable City of Ped r&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.
IArther agree to hold harmless the City of Taderal Way as to any claim(including costs, es,pensesand attorneys'fees incurred in
the investigation and defense of such claim),which may be made by any parson,Including the undersigned,and filed against the city,
but only where such claim arises out of the reliance of the city, including its of bare and employees, upon the accuracy of the
information supplied city as a part of this application. 7
led .../.--"
SIGNATURE �� iDATE v?" FS [,3
PRINT NAM '?IN G /`V'L4I/ t i
Bullctin#160—January 1,2013 Page 1 of 2 IcAHandouts\Electtical Permit Application