18-104512 RECEIVED
SEP 2 4 2018
CITY OFFEDERALWYELECTRICAL
CITY Of COMMUNITY DEVELOPMENT
Federal Way PERMIT APPLICATION
PERMIT NUMBER _ D 1 5 12
SITE ADDRESS: /d S \
� , p� A SUITE/UNIT/SPACE
PROJECT VALUATION ` ASSESSOR'S TAX/PARCEL M l v CURRENT/PROPOSED USE
$ 36 - - - - kcrt 21 2b k9
PROJECT NAME
(Tenant or Homeowner Last Name)
Act ANC onj- , CsMeiCc
-
PROJECT DESCRIPTION
Detailed description of work to
be included on this permit only
NAME PRIMARY PHONE
PROPERTY OWNER CO\i 1E `- , PaskC ( ) -
MAILING ADDRESS E-MAIL
1 01 s ga(-1(41 S- -
CITY STATE ZIP FAX
aeca1 U11 96 CO 3 ( ) -
NAME PRIMARY PHONE
Soja( \I A.\ t ctr LfzS ) 3H - 1e0c
MAILING ADDRESS E-MAIL
ELECTRICAL lJ\?JJ , aN Sfi- (.1444. Up•(tnh.CDIA/1
CONTRACTOR CITYn STATE ZIP FAX
Kfilki\AOrJa; OD, Ot`63`9 (L125 ) L{ -
WA STATE CONTRACTOR'S LICENSE# EXPIRATION DATE FEDERAL WAY BUSINESS LICENSE#
4�.I,Vb , Tr1 `'t 01 / 30 /z0;q oo-IOa,yi3-oo-(3L_
NAME PRIMARY PHONE
APPLICANT ` cL Gl[a ( ) -
MAILING ADDRESSnnE-MAIL
`J►.v1t A Ft''» V e_
CITY STATE ZIP FAX
( )
N! E \ PRIMARY PHONE
PROJECT CONTACT ,(cai cV
ic G1 G�
(425 ) c - 1503
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 p• application.
gilPSIGNATURE: DATE 1- Oky (1 G
PRINT NAME: 'CV- 11(.\) GA CS-1 Z
PERMIT CENTER+33325 8th Avenue South+ Federal Way,WA 98003-6325
253-835-2607+ FAX 253-835-2609 + permitcenter@cityoffederalway.com
Bulletin#160-April 14,2016 Page 1 of 1 k:\Handouts\Electrical Permit Application