5912 3RD DR W 2019-09-17 - Laserfiche WebLink

^ E�CTRICAL PERMIT APPLIC ION �� CITY OF EVERETT PERMIT SERVICES Neit ► /'3 3200 CEDAR STREET,EVERETT,WA 98201 (P)425-257-8810 I FAX 425-257-8857 1(E)everetteps@everettwa.gov I www.everettwa.gov/permits , ' PROJECT:MI*INF RMATION PROJECT ADDRESS: 5912 3rd DR W 1BUILDING AREA: sq ft - PROJECT TYPE: ❑ NEW CONSTRUCTION ✓❑ADDITION ❑TENANT IMPROVMENT CIREMODEL BUILDING USE: 0 SFR ❑ TOWNHOUSE ❑ DUPLEX ❑ADU ❑ MULTI-FAMILY-#OF UNITS: ❑ COMMERCIAL ELECTRICAL APPLICATION INFORMATION 8 DESCRIPTION OF WORK CONTRACT PRICE OF WORK:$ 350 ASSOCIATED BUILDING PERMIT#(if applicable): M1901-063 DESCRIBE SCOPE OF WORK: Gas furnace change out THIS INSTALLATION INCLUDES THE FOLLOWING SCOPE: (SELECT ALL THAT APPLY) LINE VOLTAGE WORK? ❑ NO ❑YES-Select Scope: ❑ Service El Feeder ❑ Circuits-#: ❑ Complete Re-wire LOW VOLTAGE WORK? ❑ NO ❑YES-#of Devices: SELECT SCOPE(REQUIRED): ❑ Data El Intercom ❑ Thermostat ❑Audio ❑ Secure Access ❑ Security System ❑ Fire Alarm- Installations under this permit only include electrical wiring rough-in of the system.An additional Fire Alarm Permit is required for review of device location and installation approval. 0 Other(List All):gas furnace reconnect .DE COMPLIANCE ' ...; IS THIS PERMIT EDUCATION, INSTITUTIONAL, HEALTH AND/OR PERSONAL CARE FACILITIES: 12 NO • YES--See Below&Pg.2 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 of this application(see next page),AND Plan Review is NOT required because I meet all of the following sub sections that do not See Page 2 require Plan Review. ARE YOU AN OWNER PERFORMING WORK AS THE CONTRACTOR WITHOUT ELECTRICAL LICENSURE:ONO OYES-See Below&Pg. 3 Pursuant to RCW 19.28.261, property owners and leaseholders cannot perform electrical work on buildings for rent,sale,or lease without the proper electrical licensing and certification, or exemption. By checking this box,I am stating that I have completed and See Page 3 signed the AFFIDAVIT on page 3 of this application to receive an exemption from this licensing/certification requirement. CONTACT, , 'TIO OWNER NAME: marko djuliarso TENANT BUSINESS NAME(If Commercial): OWNER MAILING ADDRESS: STREET 5912 3rd DR W CITY Everett STATE WA Z,p 98203 OWNER PHONE:901-359-5300 OWNER EMAIL: CONTRACTOR NAME: Black Lion Heating & Air COnditioning CONTRACTOR ADDRESS: STREETI1001 118th pl ne CITY Kirkland STATE WA ZIP 98033 CONTRACTOR PHONE:425-814-3944 CONTRACTOR EMAIL:Brenda@blacklionhvac.com CONTRACTOR LIC.#(REQUIRED):blacklh84114 CITY OF EVERETT BUSINESS LIC.#(REQUIRED):053541 PRIMARY CONTACT: ❑OWNER ❑✓CONTRACTOR ❑OTHER(Please Specify) CONTACT NAME: CONTACT PHONE:425-814_3944 b re n d a CONTACT EMAIL:brenda©blacklionhvac.corn 'AGREEMENT:I hereby comfy that I have read and exan€rited this application and know the same to be true and correct Rfl pnwlsiotis(sf k ws and Ordinances governing this .. 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 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 c smp. "the ' Contractors Law 18.27 RCW and 296,200 WAC. City of Everett Official Use OnlyPERMIT#: • ,� 2/19/2019 E 1 ! ) - of l 'Q' net* • tho `''ent Signatu t' `. Date (kovised 1/11/2019) Page 1-Application