17-100245 A stecezveo ELECTRICAL
CITY OF
Federal Way JAN I/ 2017 PERMIT APPLICATION
artrY OF FEDenAL vim PERMIT NUMBER / 7- _ / 0 o — L
SITE ADDRESS: '�Zy � 1 �PAc t t t c SUITE/UNIT/SPACE#
IA S
PROJECT VALUATION ASSESSOR'S TAX/PARCEL 4 CURRENT/PROPOSED USE
$ 20 00 / 5 0 0 5 0 - a / J c
PROJECT NAME 1
(Tenant or Homeowner Last Name) L P' Q-`L ' F'U 2
RPk_ cC-CID Ar-. (a5TNt_y cA Ex-1--ma-kc,c
PROJECT DESCRIPTION Gt{'T%.
Detailed description of work to
be included on this permit only
NAM PRIMARY PHONE
PROPERTY OWNER j_,41,t&L, 00....a) �"l�`'l ( ) -
LING ADDRESS E-MAIL
CITY STATE ZIP FAX
( )
NAME PRIMARY PHONE
CFNA142l-C-1 I)t-41rJ Etc c(Zi C (ZS1 ) -loci_ Ck2,.ct
MAILING ADDRESS E-MAIL
ELECTRICAL 2 ir\ 2 0-r, AVE s L'i-tA(Lee p c-t\•-.) el Cc:7"-K_ G c..4-4t0- L e4.--,
CONTRACTOR CITY STATE ZIP FAX
ECDC--c1P - L-A.•-iA tn.Is% C'l.F'v0"3 ( ) -
WA STATE CONTRACTOR'S LICENSE# EXPIRATION DATE FEDERAL WAY BUSINESS LICENSE k
GI--k A 2 LDS 3Q L Lt- / / _
NAME PRIMARY PHONE
APPLICANT k-el. -. L,,o,�G (753 ) ?C d- 55'1 '„
MAILING ADDRESS E-MAIL
'ZfSlu->% 7o" (1 L S', ,,:i-
CITY
'xCITY STATE ZIP FAX
k"-‘CTrGAA‘__ U)A Gl,$vo3 ( ) -
NAME PRIMARY PHONE
PROJECT CONTACT V--t t,J t r-) (2c ) 'Zs-- S 7 n 1.
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 a part of this application.
SIGNATURE: DATE 0- 0--(N- 1 /.
PRINT NAME: 1 U LU 1 .- L.'c ...3 G
Bulletin#160-April 14,2016 Page 1 of 1 k:\Handouts\Electrical Permit Application