18-102095 A. RECEIVED ELECTRICAL
CITY OF
Federal Way MAY 16 2018 PERMIT APPLICATION
FEDERALw ( Z COMMUNITY DEVELOPMENT
PERMIT NUMBER —
SUITE/UNIT/SPACE#
SITE ADDRESS: C S t.- b4-- —
PROJECT VALUATION ASSESSOR'S TAX/PARCEL# CURRENT/PROPOSED USE
$ ' oo�-O 92 1 OI _ ° 9 '/
PROJECT NAME ,
(Tenant or Homeowner Last Name) A) (&) C--e—
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PROJECT DESCRIPTION �`�` bti
- tl ,,n ,,_,,,„,t__ C L44C O .4 J z✓/ - ri cs
Detailed description of work to p n W P
be included on this permit only
NAME PRIMARY PHONE
PROPERTY OWNER A) 10(-(- (o&)({�3 - 3'6
MAILING ADDRESS E-MAIL
Pin a C P, he f ; ______ ___ ch
CITY STATE ZIP FAX
NAME w ,/ PRIMARY PHONEP
CO • C-o L. �-L n vIAQ ..r u i'Ce 5 LZ.1._ ( ) '7 7/- aCa-j C2
MAILING ADDRESS ( E-MAIL
ELECTRICAL )-0 ?% (2-1--Ave_ 11 c7TG c)-3c2 zn_!' We__ ,rt.l.[n
CONTRACTOR CITY STATE ZIP FAX
&CA--f+1e if30 9 S Id-1 ( )
W�TA'�E�N���ENSE�v pf EXPIRATION��E FEDERAL WAY BUSINESS LICENSE#
NAME �// 88 7 8 PRIMARY PHONE
APPLICANT MAILING ADDRESS - WAKE &icln CP,, 1L c ( )
E-MAIL
CITY STATE ZIPP
S3.u-'1"jw_ -1 802-1 ( )
NAME PRIMARY PHONE
PROJECT CONTACT h W r f
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 cit a4.a pizrt of this application.
SIGNATURE: -
�� DATE0.--A-1---//8
PRINT NAME: —&-rZ 714 4 W IG
Bulletin#160-April 14,2016 Page i of i k:AHandouts\Electrical Permit Application