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ELECTRICAL PERMIT APPLICATION
<br /> CITY OF EVERETT PERMIT SERVICES
<br /> 4.1
<br /> '� 3200 CEDAR STREET,EVERETT,WA 98201
<br /> (P)425-257-8810 1 FAX 425-257-8857 1(E)everetteps@everettwa.gov I www.everettwa.gov/permits
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<br /> PROJECT ADDRESS: -7A �(,�i✓} l BUILDING AREA: sq ft
<br /> PROJECT TYPE: ❑ NEW CONSTRUCTION ❑ADDITION ,LI TENANT IMPROVMENT ❑REMODEL
<br /> BUILDING USE: 1!J SFR ❑TOWNHOUSE ❑DUPLEX ❑ADU ❑MULTI-FAMILY-#OF UNITS: ❑COMMERCIAL
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<br /> CONTRACT PRICE OF WORK:$ (n)`j, I}(j ASSOCIATED BUILDING PERMIT#(if applicable):
<br /> DESCRIBE SCOPE OF WORK: j tri j k '1 Oi1(a_GCk - ? ( . -) GiG�')
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<br /> THIS INSTALLATION INCLUDES THE FOLLOWING SCOPE: (SELECT ALL THAT APPLY)
<br /> LINE VOLTAGE WORK?, ❑ NO YES-Select Scope:❑Service ❑Feeder ❑Circuits-#: ❑Complete Re-wire
<br /> LOW VOLTAGE WORK? DIV-0 ❑YES-*of
<br /> SELECT SCOPE(REQUIRED):' Data ❑ Intercom ❑Thermostat 0 Audio ❑Secure Access ❑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):
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<br /> IS THIS PERMIT EDUCATION,INSTITUTIONAL,HEALTH AND/OR PERSONAL CARE FACILITIES: ✓ NO d 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 f 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: ZNO EYES-See Below&Pg.3
<br /> Pursuant to RCW 19.28.261, 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 page 3 of this application to receive an exemption from this licensing/certification requirement.
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<br /> OWNER:NAME: TENANT BUSINESS NAME(If Commercial):
<br /> OWNER MAILING ADDRESS: STREET 2;— / Pr }7 L
<br /> CrrY v'L/ULA+: STATE UUA �I ZIP c/E-2-05
<br /> 7
<br /> OWNER PHONE: cA 1 C•7j0`2., , Gr"c`3(D OWNER:EMAIL:
<br /> CONTRACTOR NAME: gs heating
<br /> CONTRACTOR ADDRESS: STREET3409 everett ave
<br /> cry everett STATE wa ZIP 98201
<br /> CONTRACTOR PHONE:425-252-4402 CONTRACTOR EMAIL:dawn@gsheating.com
<br /> CONTRACTOR LIC.#(REQUIRED):GSHEAHC8218R CITY OF EVERETT BUSINESS LIC.#(REQUIRED):60058
<br /> PRIMARY CONTACT: DOWNER ©CONTRACTOR ❑OTHER(Please Specify)
<br /> CONTACT NAME: CONTACT PHONE:425-2524402
<br /> dawn weimer CONTACT EMAIL:dawn@gsheating.com
<br /> AGREEMENT:I 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 I
<br /> comply with the State Contractors Law 18.27 RCW and 296.200 WA C. City of Everett Official Use Only
<br /> PERMIT#:
<br /> E a - o�
<br /> 3 eriAuthorized Agent Signature Date (Revised 1/11/2019) Page 1-Application
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