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Alt,... i• ELECTRICAL PERMIT APPLICATION
<br /> CITY OF E ERETT PERMIT&EMCEE
<br /> 'r-• 3200 CEDAR STREET,EVER T,WA 98201
<br /> (P)4228-2574810 i FAX QS-2674851 1(E)everett ,- pevert ttwa.gov i vwnu everett +i rmits
<br /> PROJECT ADDRESS: t(FOG t...LOW 1),��e. t.. t/M4 BUILDIANI3 AREA: sq ft
<br /> PROJECT TYPE: 0 NEW CONSTRUCTION 0 ADDITION 121 TENANT IMPROVMENT 0 REMODEL
<br /> BUILDING USE: 1'0 SFR 0 TOWNHOUSE 0 DUPLEX 0 AI)U 0 MULTI-FAMILY-#OF UNITS: 0 COMMERCIAL
<br /> X ¢
<br /> CONTRACT PRICE OF WORK:$ 000,•v ASSOCIATED BUILDING pERmrr;#(if applicable):
<br /> DESCRIBE SCOPE OF WORK: AIPO So C't t1 - $ - ditok4 0-
<br /> ADD t S Prim.f Cti40. Or .r42 '4I" '""
<br /> THIS INSTALLATION INCLUDES THE FOLLOWING SCOPE:(SELECT ALL THAT APPLY}
<br /> LINE VOLTAGE WORK? 0 NO <YES-Select Scope:0 Service 0 Feeder t: Circuks-#; got 0 Complete Re-wire
<br /> LOW VOLTAGE WORK? 74 NO 0 YES-4 of Devices:
<br /> SELECT SCOPE(REQUIRED) 0 Data 0 Intercom Thetmostat 0 Audio 0 Secure Access 0 Security System
<br /> 0 Fire Alarm-Installations under this permit only Include cal wiring rough-in of the System.An additional
<br /> Fire Alarm Permit is required for review of device location and installation approval.
<br /> 0 Other(List A)
<br /> -W4.;„,4,,'° 7A-44,',4 •r J ;.. K_, , ^°^ •6 ..,,z'�..a W.k ..^ v���—,:10:41,,,,--'. ..._. a,.ve,a'r•� .e>z,
<br /> IS THIS PERMIT EDUCATION,INSTITUTIONAL,HEALTH ASR PERSONAL CARE FACILITIES: '' NO 0 YES-See Below&Pg.2
<br /> By checking this box,f am stating that f have read and understand aft of WAC 206-46B-9O0,selected the Specific reason on page2
<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:gNO DYES-See Below&Pg.3
<br /> ❑
<br /> Pursuant to RCW 13.28.251,property owners and leaseholders cannot perform electrical work on buildings for rent safe,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 page3 of this rapplication to receive an exemption from this licensing/certification requirement.
<br /> OWNER NAME: Q t4 get 4574.1 TENANT BUSINESS NAME tlfCommerciel):
<br /> OWNER MAIUNG ADDRESS: STREET /4,040 Att r P, L `.. Pe. U 7W C>
<br /> _ CRY 'u� �►- — . STATE 'fig
<br /> OWNER PHONE: .r +tel' ---5 ♦ OWN 11th feo e ` dv i iett a-44441
<br /> t i+ 8A"
<br /> CONTRACTOR NAME: fA ,C.
<br /> CONTRACTOR ADDRESS: s'racar IS l t /41,q 4444illittleSE
<br /> CONTRACTOR PHONE: 24,40 300 124'1 CONTRACTOR EMAIL: Gime L64 (
<br /> .
<br /> t*^'*4 ,CO"
<br /> CONTRACTOR LIC;(REQUIRES)'61 hA `0$ if 077,07- CITY OF EV ETT BUSINESS Lie.#(REQUIR D}: r~
<br /> PRIMARY CONTACT: 0OWNER (CONTRACTOR D IOmietz•(Please Specify)
<br /> CONTA T NAME: CONTACT PHONE: ', - "' 300—gel•"
<br /> AP � :�'!�" CONTTACTEMAIL: 1rr1 {'"�` ,C... „. s ', CaAlt
<br /> AGREEMENT I hereby: I&that I have ailed and examined thisf cadonand knev#re same to hebue and cormst All motesns oflaws end onlnences patvaming this
<br /> type ot work will he cold whetherspeoltied herein ornot The granting Ws pent* s row to gitva sothon&to violate oresncel the provisions ofd ofherstato or
<br /> khat Jaw regulating construction orthe perfomtance OkirlittaniCtiOn..That!ametithorized by the owner of this povertyto pem,sm!he worktorwhich eppliceition is made end!
<br /> comply with the Stele ConfradOrs Law 18,27 RCW end 296200 WAC, City of EvenntOtfioltiltkins Only.
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<br /> , 11,--2—2.4). ( 1 E I tio 14 - if (411,' 02--9 I
<br /> Owner/Authorized Agent Sign sire Date (Revised 1/1112019) Page 1-Appl tion
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