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ELECTRICAL PERMIT APPLICATION <br /> CITY OF EVERETT PERMIT SERVICES <br /> 1 T__ 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 <br /> PROJECT ADDRESS: • I$ i4IDi.zJ✓ 'BUILDING AREA: sq ft <br /> � <br /> PROJECT TYPE: 0 NEW CONSTRUCTION 1 ADDITION 0 TENANT IMPROVMENT 0 REMODEL <br /> BUILDING USE: 0 SFR ®TOWN,HOU 0 DUPLEX 0 ADU 0 MULTI-FAMILY-#OF UNITS: COMMERCIAL <br /> -ELECTRI 1" APPLI► TION I (FORMATION &:DESCRIPTION OF WORK - <br /> CONTRACT PRICE OF WORK: /r ,L /`'`' ASSOCIATED BUILDING PERMIT#(if applicable): <br /> • <br /> DESCRIBE SCOPE OF WO'K: Fi1/ZE 14-i_04,4 iii T iuEL 6iz-vpue-14 6/I2-Gu)1 <br /> i <br /> THIS INSTALLATION INCLUDES THE FOLLOWING SCOPE: (SELECT ALL THAT APPLY)n <br /> LINE VOLTAGE WORK? 0N 0 YES-Select Scope: 0 Service 0 Feeder IZl Circuits-#: I 0 Complete Re-wire <br /> LOW VOLTAGE WORK? 12 NO 0 YES-#of Devices: <br /> SELECT SCOPE(REQUIRED): <br /> 21 Data 0 Intercom 0 Thermostat 0 Audio Secure Access 0 Security System <br /> n Fire Alarm-Installations under this permit only include electrical wiring rough-in of the system.An additional <br /> =ire Alarm Permit is required for review of device location and installation approval. <br /> 0 Other(List All): <br /> ,CODE':COMPLIANCI :, <br /> IS THIS PERMIT EDUCATION,INST TUTIONAL,HEALTH AND/OR PERSONAL CARE FACILITIES: ja NO 0 YES See Below&Pg.2 <br /> El 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 OWNER PERFORMING WORK AS THE CONTRACTOR WITHOUT ELECTRICAL LICENSURE: MNO ®YES-See Below&Pg. 3 <br /> ® Pursuant to RCW 19.23.261, property owners and leaseholders cannot perform electrical work on buildings for rent, sale, or lease <br /> without the proper elec:rical 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 /> ':CONTACT INFORMATION1• . <br /> OWNER NAME: =5 i-4 eralSer 5ezJIc.O'S TENANT BUSINESS NAME(If Commercial): <br /> OWNER MAILING ADDRESS: STREET <br /> STATE ZIP <br /> CITY <br /> OWNER PHONE: OWNER EMAIL .. <br /> CONTRACTOR NAME: (IZ? ,11 i Tr 'L 71-z"I�' <br /> CONTRACTOR ADDRESS: STREET .PO 5X Zyce) <br /> CITY :T - STATE (,.[,}l4 ZIP `46Z13 <br /> CONTRACTOR PHONE: CONTRACTOR EMAIL: � �2 <br /> �- EVERETT BUSINESS LIC #(REQUIRED) <br /> CONTRACTOR LIC.#(REQUIRED). I'Ui� e../! 7e,-3ICITY OF ""'"� <br /> PRIMARY CONTACT: 0 OWNEF, ®CONTRACTOR� ���� �� �• -� ❑OTHER(Please Specify) <br /> CONTACT NAME: CONTACT PHONE: -1-75- 33) /SSC) /� <br /> CONTACT EMAIL: c'cy✓(/fh e/ecf?'t�b (-i j vvici.C' , c.c'�(4 <br /> AGREEMENT.'I hereby certify that I have lead and examined this application and know the same to be true and correct. All provisions o aws 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 pen ormance of construction. That I am authorized by the owner of this property to perform the work <br /> oroof for which Opic licaati ion Use Only is made and I <br /> comply with the State Contractors Law 18.:?7 RCW and 296.200 WAC. PERMIT#: <br /> Xtictigg------ / - /z _,i E nepc _O4-s <br /> Owner/Authorized Agent Signature Date <br /> (Revised 1/11/2019) Page 1-Application <br />