18-100255 CITYOFa....._4 a 1 4 RECEIVEDELECTRICAL
Federal Way PERMIT APPLICATION
JAN 16 2018
CITY OF FEDERAL WAY PERMIT NUMBER d 0 O� S
COMMUNITY DEVELOPMENT g - -
SITE ADDRESS: -3. 261-`QsulTE/ SPAk
10� S .
PROJECT VALUATION ASSESSOR'S TAX/PARCEL# CURRENT,( OPOSED USE
/ 500 __,3a 9-- 8' D o _ 00 3o
PROJECT NAME
(Tenant or Homeowner Last Name) Oftc Ips/. Jp Lkst e_.
PROJECT DESCRIPTION
tr -,A--j ure! 's
Detailed description of work to
be included on this permit only
NAME PRIMARY PHONE
PROPERTY OWNER 1-41-\ M, ( ) -
MAILING ADDRESS E-MAIL
CITY STATE ZIP FAX
( ) -
NE . - ---_PRIMARYPHONE
F-1-0u-L Ao.riAk
MAILING ADDRES J E-MAIL
ELECTRICAL &(j I -c
CONTRACTOR cI `( STA zI FAX
� .i 1 a-- Op v / E ( ) -
WA STATE CONTRACTOR'S LICENSE# EXPIRATION DATE FEDERAL WAY BUSINESS LICENSE#
TRou..LPl s /31 //S
NAME �-- Y PRIMARY PHONE
APPLICANT
5,.....0.,_42._. a_ Co-N 'r �� ( ) -
MAILING ADDRESS E-MAIL
CITY STATE ZIP FAX
( )
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 arty 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.
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pSIGNATURE: DATE iii ci �g
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PRINT NAME: cQ
Bulletin#160—April 14,2016 Page 1 of 1 k:\Handouts\Electrical Permit Application