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.11 L' ECTR CAL PERMIT ,4\PPLIGI.%110N
<br /> /4/A* - CITY OF EVERETT PERMIT SERVICES
<br /> 3200 CEDAR STREET, EVERETT,WA 98201
<br /> (P)425-257-8810 I FAX 425-257-8857 I(E)everetteps@everettwa.gov I www.everettwa.gov/permits
<br /> PROJECT'SITE:IFIP.ORN ATIOF1 '
<br /> .�PROJECT ADDRESS: b-... 4,0 . Cv-Ciccx-u lea (BUILDING AREA: sq ft
<br /> PROJECT TYPE: IECNEW CONSTRUCTION 0 ADDITION DUI TENANT IMPROVMENT 0 REMODEL
<br /> BUILDING USE: 0 SFR 0 TOWNHOUSE 0 DUPLEX 0 ADU 0 MULTI-FAMILY-#OF UNITS: ®COMMERCIAL
<br /> ELECTRICAL,APPLICATION;INFORMATION 8'DESCRIPTION OP WORK :, .
<br /> CONTRACT PRICE OF WORK:$ B- (� e� 0/600(',) -- (ASSOCIATED BUILDING PERMIT#(if applicable):
<br /> DESCRIBE SCOPE OF WORK: AC, bQ Int S;vs.cd t elu,t,r— 4 tv c.z c- V € -1
<br /> U CC;7 MA W 1 rr...I e 55 e‘r. -±Cc l--c&A:'W cIA.:ic- e-i k.d t-LS--. C.rt.u..i } -'aw\
<br /> THIS INSTALLATION INCLUDES THE FOLLOWING SCOPE: (SELECT ALLTHAT APPLY)
<br /> LINE VOLTAGE WORK? NO OYES-Select Scope:'L>JI Service lar Feeder aCircuits-#: 0 Complete Re-wire
<br /> LOW VOLTAGE WORK? NaNO 0 YES-#of Devices:
<br /> SELECT SCOPE(REQUIRED):
<br /> 0 Data 0 Intercom 0 Thermostat 111 Audio '0 Secure Access 0 Security System
<br /> 0 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 /> ..CODE;COMPLIANCE:' ...�
<br /> IS THIS PERMIT EDUCATION,INSTITUTIONAL,HEALTH AND/OR PERSONAL CARE FACILITIES: `YJ NO 0 YES--See Below&Pg.2
<br /> 0 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: ®AO ®YES-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: VL xNA:ie, V cSCL/N, TENANT BUSINESS NAME(If Commercial): Q ex;Zorn ( 1 c- XCc 5
<br /> OWNER MAILING ADDRESS: STREET f(Dtc( ". �L G�)� (� P
<br /> STATE t�� ZIP -1 -IQV
<br /> CITY „,la ���.�_.����
<br /> OWNER PHONE: 7 •. OWNER EMAIL ...,_- -b,, ._.,
<br /> „sx
<br /> CONTRACTOR NAME: f� t"'t- pi C-c.„-" re__- ,(,
<br /> CONTRACTOR ADDRESS: STREET `A611 p�,,F k c ,' ,�/(��
<br /> STATE `(A- ZIP 184(�(,J
<br /> crrY cA
<br /> 1 Q , f
<br /> CONTRACTOR PHONE: nn,,�, (CONTRACTOR EMAIL: ,,, ,, 1 e c-C9c.f4 1tGC `•,.— •�C-'
<br /> CONTRACTOR LIC.#(REQUIRED) ,)e �l 3aL b ICITY OF EVERETT BUSINES LIC #(REQUIRED) S A 7,3
<br /> PRIMARY CONTACT:., . p Specify)
<br /> ❑OWNER ►== ONTRACTOR 0 OTHER(Please S eci
<br /> CONTACT NAME: CONTACT PHONE: a,�3--405 - Ce0-7 / 9
<br /> ® A .O4�" 4A`C�`-i'CS CONTACT EMAIL: ItjaA..t-�tO_ r/?L i-g.-, 'c (C.-,A)
<br /> AGREEMENT:I hereby certify that I have read and examined this application and know the same to be true and correct. A 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 C work
<br /> for
<br /> whicht Officiation
<br /> atil n Use Only yis e and I
<br /> comply with the State Contractors Law 18.27 RCW and 296.200 WAC. PERMIT#:
<br /> — . at
<br /> E ( 4/001`602
<br /> • er/Au yonzefent Signature Date (Revised 1/11/2019) Page 1-Application
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