17-104061 ELECTRICAL
CITY OF I A
Federal Way PERMIT E&R sATION
PERMIT NUMBER l _ 1 0 4- 0 V t _ Co AUG 2 2 207
CITY OF FEDERAL WAY
COMMUNI I) fiffeitiLOPMEWE#
SITE ADDRESS:
3 R b. Pocfcc, 1 w y s 1- , (j) L0,4- 700�3
PROJECT VALUATION ASSESSOR'S TAX/PARCEL# CURRENT/PROPOSED USE
$ `71 goo, 0-a O 9 z I - 2 9
PROJECT NAMER ,��+
(Tenant or Homeowner Last Name) o,n�-c, [ C(4Jt) �''v��Z i d I) 1.-0 0 0c)1 . 1-k-Sr=i. ---T:\+-ere Al s yS I rl,
PROJECT DESCRIPTION G`r\-0 r)rc te- (U^T r r r4.\_u-4`y9 n LA n ;-1-,
Detailed description of work to
be included on this permit only
NAME '� ,, PRIMARY PHONE
PROPERTY OWNER 1((A"C 19 ,R ,(A) T c-t5 " F cid.-t i-i/c:, ()6 ) 79G - 0 (SS
MAILING ADDRESS A
] E-MAIL
3c6uc,
pQ c 8nc.11 ).rtild, esCUS e1ha:l,(.1^/VI
CI STATE ZIP FAX
{cterU { W6.7 (-04 Boo ( ) -
NAME PRIMARY PHONE
,7OtAnd Mas s ti,C ( c ) 63 -- 1-I3L3
MAILING ADDRESS E-MAIL
ELECTRICAL tt 0 tt 5 (.J&j lV C{, ,51,,d(JScc...cl In(,64P5•5;.`)C:CO ru
CONTRACTOR CITYSTAT ZIP FAX
�cGtiN cle l6*--s (1b(, ) 6) - ac)q-
WA STATE CONTRACTOR'S LICENSE# EXPIRATION DATE FEDERAL WAY BUSINESS LICENSE#
. tuna0'‘, 07Inli1 / 30 / ( 7
.. .. NAME r rr ..,, u - - -
-- PRIMARY PHONE
APPLICANT Cc '5 W .1 So.A ( ) ( ) 7 qS- 6V-S-
MAILING ADDRESS t/ i.� ' I J E-MAIL 1
`1 UL I cJ u (/ G'•- 1 01/‘ C.,)OSaAnc)Ma.ST-e^5 .'nt.CL1^t
CITY Q� /GT ZIP q 1 A �� FAX �G�
C (ab ) 1
NAMEPRIMARY PHONE
/
PROJECT CONTACT 0,r _S WI visor ()G ) 7 IS- 6-9/ 5-
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 a part of this applica on.
SIGNATURE: t4 L/ V DATE e " --)- - [-7
PRINT NAME: Ck r ' W ? ( 0./N
Bulletin#160—January 1,2013 Page 1 of 2 161-Iandouts\Electrical Permit Application