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06/25/2019 10: 03 3604740126 DONNELSON ELECTRIC INC #4053 P. 001 /001
<br /> hLECTRICAL PERMIT APPLICATION
<br /> EVERETT 32CITY OF EVERETT PERMIT SERVICES
<br /> 00 CEDAR STREET,EVERETT,WA 98201
<br /> WASH a N GTON. (P)425-257-8810 I FAX 425-257-8857 (E)everetteps@everettwa.gov I www.everettwa.gov/permits
<br /> AMINICHENEMENESSESEMEMEITO=LIMINMESEMENNAMEMENER
<br /> PROJECT ADDRESS: 6f O 6u.). 'eCeT3 rAo. (,jj4r.' BUILDING AREA; 11:100 sq ft
<br /> PROJECT TYPE: ❑ NEW CONSTRUCTION El ADDITION El TENANT IMPROVMENT ' REMODEL
<br /> BUILDING USE: ❑SFR ❑TOWNHOUSE 0 DUPLEX El ADU ❑ MULTI-FAMILY-#OF UNITS: COMMERCIAL COMMERCIAL
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<br /> CONTRACT PRICE OF WORK:$ 'f ASSOCIATED BUILDING PERMIT#(if applicable):
<br /> DESCRIBE SCOPE OF WORK;
<br /> Add 60" (et5 }N NVQ ie /2 AR its
<br /> •
<br /> THIS INSTALLATION INCLUDES THE FOLLOWING SCOPE: (SELECT ALL THAT APPLY)
<br /> LINE VOLTAGE WORK? ❑ NO M--YES-Select Scope: ❑Service El Feeder -Circuits-t_ ❑Complete Re-wire
<br /> LOW VOLTAGE WORK? El NO El YES-#of Devices: ".
<br /> SELECT SCOPE(REQUIRED): ❑ Data ❑ 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 /> El Other(List Al]):
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<br /> IS THIS PERMIT EDUCATION,INSTITUTIONAL,HEALTH AND/OR PERSONAL CARE FACILITIES: 74 NO YES—See Below&Pg.2
<br /> [L 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: ?]NO DYES-See Below&Pg.3
<br /> E. Pursuant to ROW 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 onpage 3 of this application to receive an exemption from this licensing/certification requirement.
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<br /> OWNER NAME: J00V CUC,,t__ TENANT BUSINESS NAME(If Commercial);
<br /> OWNER MAILING ADDRESS: STREET Cj(0 SL.&J at/e4- --T7 (Yv: Ulortr7ZZY-1
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<br /> OWNER PHONE: 'OWNER EMAIL:
<br /> CONTRACTOR NAME: ._� _.‘c,,i'vk) � -1JL
<br /> CONTRACTOR ADDRESS: STREET I!3.1 A.10-11V\ Qlijiv.- ),(.— ,4�e
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<br /> CONTRACTOR PHONE: 92S—.5 (o`//8 CONTRACTOR EMAIL: �nilelc�,, .
<br /> CONTRACTOR LIC.#(REQUIRED): Dem ee;a yypz. CITY OF EVERETT BUSINESS LIG.#(REQUIRED): 0 837
<br /> AN'dY WNPYf,W'.N'dLlxunw.wmxWamhw'N'.wW'Mwwpa'
<br /> PRIMARY CONTACT: ❑OWNER ONTRACTOR LOTHER(Please Specify)
<br /> CONTA?T NAME: CONTACT PHONE: 3.51—6W8 •
<br /> C)r} CONTACT EMAIL: CS4 + e
<br /> AGREEMENT:I hereby certify that 1 have read end 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 presurne to give authority to violate or cancel the provisions of any other state or
<br /> focal law regulating construction or the performance of constrUetion, That I am authorized by the owner of this property to perform the work for which application is made and 1
<br /> comply with the State Contractors Law 18.27 RCW and 296.20. a AC. City of Everett Official Use Only
<br /> PERMIT#:
<br /> own _,:.`0 1 gn:re re Date • (RCvised 1/11/2019) Page 1-Application
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