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ELECTRICAL PIMMIT & FIRE ALARM PIT APPLICATION <br /> CITY OF EVERETT PERMIT SERVICES <br /> 4 (Ole—rr. _ 3200 CEDAR STREET, EVERETT,WA 98201 <br /> (P)425-257-8810 I FAX 425-257-8857 I (E)everetteps@everettwa.gov I www.everettwa.gov/permits <br /> PROJECT SITE INFORMATION <br /> PROJECT ADDRESS:)L \-10-2_ V iVL6f„i-' A,-)C—; CV l Ute'. 392.0 1 <br /> PROJECT TYPE: 0 NEW CONSTRUCTION 0 ADDITION 0 TENANT IMPROVMENT 0 REMODEL <br /> BUILDING USE: 0 SFR 0 TOWNHOUSE 0 DUPLEX 0 ADU 0 MULTI-FAMILY-#OF UNITS: ❑COMMERCIAL <br /> BUILDING AREA: sq ft <br /> ELECTRICAL APPLICATION INFORMATION <br /> CONTRACT PRICE OF WORK:$rY" cn,C'L ASSOCIATED BUILDING PERMIT#(if applicable): <br /> IS THIS LOW VOLTAGE WORK? 0 NO 0 YES-#OF DEVICES: <br /> IS THIS A FIRE ALARM PERMIT? 0 NO 0 YES-Plans required for review(Both Electrical and Fire Department inspections are required) <br /> DESCRIPTION OF WORK & CODE COMPLIANCE <br /> DESCRIPTION OF WORK: It- Rha C.& ,N (',+,JCS eiNe 5- To SSV Sb <br /> ?o v•icrk- CA...) be- 04)&4(.66 of fb'l Rs,0 <br /> IS THIS PERMIT EDUCATION,INSITUTIONAL,HEALTH AND/OR PERSONAL CARE FACILITIES: 0 NO 0 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 LYES-See Below&Pg.3 <br /> lgPursuant to RCW 19.28.261,property owners and leaseholders cannot perform electrical work on buildings for rent,sale,or lease without <br /> the proper electrical licensing and certification,or exemption.By checking this box,I am stating that I have completed and signed the <br /> See Page 3 AFFIDAVIT on page 3 of this application to receive an exemption from this licensing/certification requirement. <br /> CONTACT INFORMATION <br /> ' 6WNER NAME: '(L44..J PjRv At PJs..16%Ok TENANT BUSINESS NAME(If Commercial): <br /> OWNER MAILING ADDRESS: STREET 1-7!2 V'fl.(9`n' -Ar A;J& <br /> GVCLG l C- CITY SNP' STATE WA zip cteZ0 1 <br /> OWNER PHONE: OWNER EMAIL: <br /> CONTRACTOR NAME: <br /> CONTRACTOR ADDRESS: STREET <br /> CITY STATE ZIP <br /> CONTRACTOR PHONE: CONTRACTOR EMAIL: <br /> CONTRACTOR LIC:#(REQUIRED): CITY OF EVERETT BUSINESS LIC.'#(REQUIRED): <br /> PRIMARY CONTACT: 0 OWNER 0 CONTRACTOR 0 OTHER(Please Specify) <br /> CONTACT NAME: CONTACT PHONE: <br /> CONTACT EMAIL: <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 <br /> 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 <br /> provisions of any other state or local law regulating construction or the performance of construction. That I am authorizea by the owner of this property to perform the <br /> work for which application is made and 1 comply with the State Contractors Law 18.27 RCW and 296.200 WAC. <br /> City of Everett Official Use Only <br /> PERMIT# <br /> --.----, til z, (I 6 0. \2-. 1(33 <br /> Owner/Authorized Agent Signature Date (Revised 11/5/2018) Page 1-Application <br /> ---- <br /> I3 <br />