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111 ism. <br /> az ELECTRICAL PERMIT APPLICATION <br /> EVERETT CITY OF EVERETT PERMIT SERVICES <br /> 3200 CEDAR STREET,EVERETT,WA 98201 <br /> WASHINGTON (P)425-257-8810 I FAX 425-257-8857 1(E)everetteps@everettwa.gov I www.everettwa.gov/permits <br /> PROJECT SITE INFORMATION <br /> PROJECT ADDRESS: 3 oU 3 (,-,.) CA S))4(0 112D BUILDING AREA: sq ft <br /> PROJECT TYPE: ❑ NEW CONSTRUCTION ❑ADDITION TENANT IMPROVMENT ❑ REMODEL <br /> BUILDING USE: ❑SFR ❑TOWNHOUSE El DUPLEX ❑ADU ❑ MULTI-FAMILY-#OF UNITS: COMMERCIAL <br /> ELECTRICAL APPLICATION INFORMATION & DESCRIPTION OF WORK <br /> CONTRACT PRICE OF WORK:$ ) SO , o c ASSOCIATED BUILDING PERMIT#(if applicable): <br /> DESCRIBE SCOPE OF WORK: 1 14,S.Tfk.L,` c 4— ‘4%a pr c... L, A 1 .S TL - C U1--0 <br /> Wf\--cz2 42.4k r.% A.--T- Qvt....n.,.< -/S- 99 ,' A,-LL STA-LL.- IIS \ <br /> THIS INSTALLATION INCLUDES THE FOLLOWING SCOPE: (SELECT ALL THAT APPLY) <br /> LINE VOLTAGE WORK? ❑ NO XI YES-Select Scope: ❑Service ❑ Feeder pq Circuits-#: I ❑ Complete Re-wire <br /> LOW VOLTAGE WORK? El NO ❑YES-#of Devices: <br /> SELECT SCOPE(REQUIRED): ❑ Data El Intercom ❑Thermostat ❑Audio ❑ Secure Access ❑Security System <br /> ❑ Fire Alarm-Installations under this permit only include electrical wiring rough-in of the system.An additional <br /> Fire Alarm Permit is required for review of device location and installation approval. <br /> ❑Other(List All): <br /> DDoE=COMPLIIANCS ' 4_ <br /> IS THIS PERMIT EDUCATION,INSTITUTIONAL,HEALTH AND/OR PERSONAL CARE FACILITIES: NO n YES--See Below&Pg.2 <br /> By checking this box, I am stating that I have read and understand all of WAC 296-46B-900,selected the specific reason on page 2 <br /> of this application(see next page),AND Plan Review is NOT required because I meet all of the following sub sections that do not <br /> See Page 2 require Plan Review. <br /> ARE YOU AN OWNER PERFORMING WORK AS THE CONTRACTOR WITHOUT ELECTRICAL LICENSURE: rg,NO DYES-See Below&Pg.3 <br /> Pursuant to RCW 19.28.261,property owners and leaseholders cannot perform electrical work on buildings for rent,sale,or lease <br /> without the proper electrical licensing and certification,or exemption. By checking this box, I am stating that I have completed and <br /> See Page 3 signed the AFFIDAVIT on page 3 of this application to receive an exemption from this licensing/certification requirement. <br /> CONTACT INFORMATION . _.. , <br /> OWNER NAME: RC' j,#.(67 TENANT BUSINESS NAME(If Commercial): ,Rd/."p(.T <br /> OWNER MAILING ADDRESS: STREET 3./00"�'I . T t.„)t.„) CAS/AlU ,Qa I �'Q <br /> CITY 8 !/ 426 r STATE 1e' /f ZIPS t:-?O y <br /> OWNER PHONE: OWNER EMAIL: <br /> CONTRACTOR NAME: /lel S eiq Lr L fir_IR/ G. <br /> CONTRACTOR ADDRESS: STREET 9&22 S�O�cf A✓C� <br /> CITY Sts-i( LGSSTATE /"..../.4 ZIP 9�$2[/ <br /> U3 <br /> CONTRACTOR PHONE:211 7, 3 L/525 CONTRACTOR EMAIL: ,(,i‘1/LC.)A.[&alielSdi.,i5.d C, C Oyr( <br /> CONTRACTOR LIC.#(REQUIRED): /✓GrL SULr/Z o.0 .. CITY OF EVERETT BUSINESS LIC.#(REQUIRED): cof y7e) <br /> PRIMARY CONTACT: DOWNER [.CONTRACTOR ❑OTHER(Please Specify) <br /> CONTACT NAME: CONTACT PHONE: v2o�..0 T6-41 971 5- <br /> ,ex-A.1-7. W)/Lc- /A/67 CONTACT EMAIL: ?let /LI_/,,,iG a Ale-,Sait,I LsC LSC, e,,,,,] <br /> AGREEMENT:I hereby certify that I have read and examined this application and know the same to be true and correct. All provisions of laws and ordinances governing this <br /> type of work will be completed whether specified herein or not. The granting of a permit does not presume to give authority to violate or cancel the provisions of any other state or <br /> local law regulating construction or the performance of construction. That I am authorized by the owner of this property to perform the work for which application is made and I <br /> comply with the State Contractors Law 18.27 RCW and 296.200 WAC. City of Everett Official Use Only <br /> / PERMIT#: <br /> I. .../07/07, —_—___._ate _/y E t \O( - O02_(4O ner/Authori ed Agent Signator (Revised 1/11/2019) Page 1-Application <br />