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. ELECTRICAL PERMIT APPLICATION
<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 f www.everettwa.govlpermits
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<br /> PROJECT°SITEl4NF,:ORMATION r.;°':<.:->g:_.='
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<br /> PROJECT ADDRESS: 4432 HOYT AVE BUILDING AREA: sq ft r
<br /> PROJECT TYPE: ❑NEW CONSTRUCTION ✓❑ADDITION ❑TENANT IMPROVMENT El REMODEL
<br /> BUILDING USE: 0 SFR ❑TOWNHOUSE ❑ DUPLEX El ADU ❑MULTI-FAMILY-#OF UNITS: El COMMERCIAL
<br /> ,: ,MLECTRI.CAL-,,,APPLICATION;INFORMATI,ON;i&,gDESCRIPTION„;OFiWORK` ;_,
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<br /> CONTRACT PRICE OF WORK:$ 10266.07 ASSOCIATED BUILDING PERMIT#(if applicable):
<br /> DESCRIBE SCOPE OF WORK:
<br /> HEAT PUMP DISCONNECT+ SERVICE OUTLET
<br /> THIS INSTALLATION INCLUDES THE FOLLOWING SCOPE: (SELECT ALL THAT APPLY)
<br /> LINE VOLTAGE WORK? ❑ NO ❑YES-Select Scope:❑Service ❑ Feeder ©Circuits-#:2 ❑Complete Re-wire
<br /> LOW VOLTAGE WORK? ©NO ❑YES-#of Devices:
<br /> SELECT SCOPE(REQUIRED): Cl Data ❑ Intercom 0 Thermostat ❑Audio ❑Secure Access El 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 /> ❑Other(List All):
<br /> , iO?f,„ > „t, `: O•,DE&(COIII'I P,,LIANCE;
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<br /> IS THIS PERMIT EDUCATION,INSTITUTIONAL,HEALTH AND/OR PERSONAL CARE FACILITIES: ©NO El YES—See Below&Pg.2
<br /> 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 EYES-See Below&Pg.3
<br /> I I 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.
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<br /> OWNER NAME: JANICE LAGUTANG TENANT BUSINESS NAME(If Commercial):
<br /> OWNER MAILING ADDRESS: STREET 4432 HOYT AVE
<br /> c,Tv EVERETT STATE WA ZIP 98201
<br /> OWNER PHONE:2068988281 OWNER EMAIL:JLAGUTANG@GMAIL.COM
<br /> CONTRACTOR NAME: gs heating
<br /> CONTRACTOR ADDRESS: STREET 3409 everett ave
<br /> Crry everett STATE wa ZIP 98201
<br /> CONTRACTOR PHONE:425-252-4402 CONTRACTOR EMAIL:ALISHA@gsheating.com
<br /> CONTRACTOR LIC.#(REQUIRED):GSHEAHC8218R CITY OF EVERETT BUSINESS LIC.#(REQUIRED): 60058
<br /> PRIMARY CONTACT: DOWNER ❑✓CONTRACTOR DOTHER(Please Specify)
<br /> CONTACT NAME: CONTACT PHONE:425-252-,4402
<br /> ALISHA CLOGSTON CONTACT EMAIL:ALISHA@gsheating.com
<br /> AGREEMENT.:/hereby certify that 1 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 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 work for which application is made and 1
<br /> comply with the State Contractors Law 18.27 RCW and 296.200 WAC. City of Everett Official Use Only
<br /> PERMIT#:
<br /> ALISHA CLOGSTON E `c\oO \.2.
<br /> OwnerlAuthorized Agent Signature Date (Revised 1/11/2019) Page 1-Application
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