18-105452 RECEIVED
ELECTRICAL
CITY OF NOV 15 2018
Federal Way PERMIT APPLICATION
CITY OF FEDERAL WAY
COMMUNITY DEVELOPMENT
•
PERMIT NUMBER I S _ 1 D 5 1/ 5 2 _
SUITE/UNIT/SPACE N
SITE ADDRESS: 2. 2__ aft14 P!• 5W
PROJECT VALUATION ASSESSOR'S TAX/PARCEL M CURRENT/PROPOSED USE
$ 5:s=,CD 8 ? 3 I 9 3 - O '? a
PROJECT NAME
(Tenant or Homeowner Last Name) AVC` f k c /V ick4IUS kacI e.I
PROJECT DESCRIPTION (00A-1,1 LAK4 e_C3(c L L4 4-42-1412 PO Via&
Detailed description of work to
be included on this permit only
NAME PRIMARY PHONE
PROPERTY OWNER U)0. ( cc N 1 Ch,0)okS 1 �c cl1 e I ( ) -
MAILING ADDRESS E-MAIL
3Z2O 2 q owl
CITY STATE ZIP FAR
re-4-,o_(a I W41, WA 5202-1 ( )
_-_...._. .. NAME - PRIMARY PHONE
W E/ 4-rlc_0.( L..LC_ (Z53)Za'8 -6363
MAILING ADDRESS E-MAIL
ELECTRICAL 15507 L-L4 20 deer- Ikl
CONTRACTOR CITY STAT ZIP FAX
1.�k�w0 kA)Fl 98 Y ( ) -
WA STATE CONTRACTOR'S LICENSE N EXPIRATION DATE FEDERAL WAY BUSINESS LICENSE k
V1/4A) LEEL 8B€NP $ / Z6/2-o21D
NAME ._v..` - -- PRIMARY PHONE
e
APPLICANT Cehl2Gtd" PO�,a,1Mr p (Z63 )Z-o 6303
MAILING ADDRESS /_r / L E-MAIL
q d 7 L- zac/e /k 5 Gc/
CITY STATE ZIP FAX
L iZu}(., 4 IA) 3g%95 ( ) -
NAME PRIMARY PHONE
PROJECT CONTACT „CZ r_9(, 816 ) 2D7-goz7
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: G DATE / C)f
PRINT NAME: 61 ei'1 K R d/' £Olticgh-€i L
Bulletin#160-April 14,2016 Page 1 of 1 k:\Handouts\Electrical Permit Application