18-101861 RECEIVED ELEC'T'RICAL
CITY OF
Federal Way MAY 01 2018 PERMIT APPLICATION
CITY OF FEDERAL WAY
COMMUNTY DEVELOPMENT 6
PERMIT NUMBER ) 0 _ 10 1 O / _ c I
3UITE/UNIT/SPACE# 703SITE ADDRESS: \\L\ CJ Z�A\i\, 43�. W103 'ansa. \}`r`kilk1/
PROJECT VALUATION ASSESSOR'S TAX/PARCEL#
CURRENT/PROPOSED USE
$ 3SOe. oo z 0 2 I 0 1 - ci ! /
PROJECT NAME
(Tenant or Homeowner Last Name)
Pc� . onP. c,rc, �\-- aRA NVQ. 113 0.-3
PROJECT DESCRIPTION
Detailed description of work to
be included on this permit only
NAME `r PRIMARY PHONE
PROPERTY OWNER I)0�( Z2nl~\�D\)5\(\y ( 253) VlA - C/1.5
MAILING ADDRESS E-MAIL
1\\l `1-\\k \-' 0-c A e.Dc,OAt. 1
CITY �� �� STATE ZIP FAX
rod c
i V Gg003 (25) )%1`k- k51\
NAMEPRIMARY PHONE
C\- kpA l r 5 (-63) 73_5 - -.\\,\,3-)
MAILING ADDRESS -1 E-MAIL
ELECTRICAL 2,51% 1Zn Owe- cl rtW L0'0 �,0J6e,,\'c;,,Ocoo'cv4,44
CONTRACTOR CITYSTATE ZIP FAX
G`y AriA;r \,J P, 00.335 ( ) -
WA STATE CONTRAC R'S LICENSE# \J e't A QEXPIRATION DATE FEDERAL WAY BUSINESS LICENSE#
057 7 20 --
NAME �'7'�►'\ PRIMARY PHONE
,e��`� Vsc& (Zb5 ) 41'1_7 k- . _
APPLICANT MAILING ADDRESS E-MAIL
(16 A 22hX C-& a.►IW /�v/�c„ti>7 Us l,40rornC.i 'M.r-
CITY �STATE ZIP FAX
G5 %A
C \IN' 'kW.' ( ) -
NAME PRIMARY PHONE
PROJECT CONTACT ( )
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: 4 � DATE S /1 l��b
PRINT NAME: / .t/ Y\ (V S t.4ln
Bulletin#160—April 14,2016 Page 1 of 1 k:\Handouts\Electrical Permit Application