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<br /> ' ,--,4,0107,,,,Ni'''eS—A ELECTRICAL PERMIT APPLICHON
<br /> CITY OF EVERETT PERMIT SERVICES
<br /> 3200 CEDAR STREET,EVERETT,WA 98201
<br /> (P)425-257-8810 I FAX 425-257-8857 1(E)everetteps@everettwa.gov I www.everettwa.gov/permits
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<br /> EISSSSSIPPAISW
<br /> PROJECT ADDRESS: /5;-Z 5- 7,.7 't Sliverf31,1, hod (BUILDING AREA: sq ft
<br /> PROJECT TYPE: 0 NEW CONSTRUCTION '"ADDITION El TENANT IMPROVMENT 0 REMODEL
<br /> BUILDING USE: 0 SFR 0 TOWNHOUSE ❑DUPLEX 0 ADU MULTI-FAMILY #OF UNITS , 1OMMERCIAL
<br /> @ L EEPTR!CAAFI1T , O * .1 01000 1 my M
<br /> CONTRACT PRICE OF WORK:$ y 5---00 'ASSOCIATED BUILDING PERMIT#(if applicable):.
<br /> DESCRIBE SCOPE OF W9RK: / c'/ri`c.Gc,y-- J0 ,e1.-0 Icto,..h fi et
<br /> —7'- (1 Liele Va int MO ivi c©7''f eQ eva.h eleVtdoc)
<br /> _ W/144. v 2 C0,4. 1 sfC ons.
<br /> THIS INSTALLATION INCLUDES THE FOLLOWING SCOPE: (SELECT ALL THAT APPLY)
<br /> LINE VOLTAGE WORK? 0 NO )*ES-Select Scope:
<br /> 0 Service 0 Feeder Circuits-#: / 0 Complete Re-wire
<br /> LOW VOLTAGE WORK? 0 NO ,11 YES-#of Devices: 2.
<br /> SELECT SCOPE(REQUIRED):
<br /> ®Data 0 Intercom 0 Thermostat 0 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 eview of device locatio a d instaallati (n approval.
<br /> 0 Other(List All): a lite-,144- X0F1 h/ `SI�t,4 n s
<br /> ...AV M 3••_ 1" F i ". ACPII_pAIMM �(ea�,�`h..,. _ �.. .1
<br /> IS THIS PERMIT EDUCATION,INSTITUTIONAL,HEALTH AND/OR PERSONAL CARE FACILITIES: NO w U 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- 0,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 OYES-See Below&Pg.3
<br /> ® Pursuant to RCW 19.28.261,property owners and leaseholders cannot perform electrical work on uildings 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 /> ra eSa..r° a 1 nt ymSSS m <vx ., R / S<.,.A _.., rs. .:co n :ti.i.F.-,e'•., im ',. ..
<br /> OWNER NAME: TENANT BUSINESS NAME(If Commercial
<br /> OWNER MAILING ADDRESS: STREET
<br /> STATE ZIP
<br /> CITY
<br /> OWNER PHONE: OWNER EMAIL:
<br /> CONTRACTOR NAME: ,Zdr-kO Ek'^c/7'/. G.
<br /> CONTRACTOR ADDRESS: STREET pt 0 0 o fa0 1.41
<br /> _)�/�} /y��/�//yam
<br /> CITY L,- IA.,va-1/ STATE W! J ZIP 7O V
<br /> CONTRACTOR PHONE: 9(25-2,112-77/0 7/O(CONTRACTOR EMAIL: MG.f'cell COZo1'k0 e1.pc ri` .Cour►
<br /> CONTRACTOR LIC.#(REQUIRED): Z 0 0 2, E CITY OF EVERETT BUSINESS LIC.#(REQUIRED):
<br /> PRIMARY CONTACT: 0 OWNER 4CONTRACTOROTHER(Please Specify) /
<br /> CONTACT NAME: CONTACT PHONE: g-0(7V96 -1/739
<br /> ?ar' ec ,/� ?h e't t it0�,9GI CONTACT EMAIL: -Pa I`Jler.y»gi) 7.6 I'ka elect^)k ,COv 1
<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 is any other state or
<br /> local law regulating con - bn or the perfor ante of construction. That I am authorized by the owner of this property to perform the City for
<br /> Everett Official application s ma Only and 1
<br /> 7
<br /> comply with the St- - -•ntractors Law ,< 7 RCW and 296.200 WAC. LPMI
<br /> T#:
<br /> Owner/Authorized Agent Signaturo-
<br /> Date (Revised 1/11/2019) Page 1-Application
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