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08/21/2019 13 ' 13 44376 P. 001/002
<br /> l� ELECTRICAL PERMIT APPLICATION
<br /> CITY OF EVERETT PERMIT SERVICES
<br /> EVERETT 3200 CEDAR STREET,EVERETT,WA 98201
<br /> (P)425-257-8810 I FAX 425-257-8857 I(E)everettepsl everettwa.gov I www.everettwa.gov/permits
<br /> WASHINGTON
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<br /> PROJECT ADDRESS: 3430 COLBY AVE BUILDING AREA: sq ft
<br /> PROJECT TYPE: ❑ NEW CONSTRUCTION ❑ADDITION 0 TENANT IMPROVMENT Q REMODEL
<br /> BUILDING USE: El SFR ❑TOWNHOUSE CI DUPLEX ❑ADU CI MULTI-FAMILY-#OF UNITS: Q COMMERCIAL
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<br /> CONTRACT PRICE OF WORK:$ 1200 ASSOCIATED BUILDING PERMIT#(if applicable):
<br /> DESCRIBE SCOPE OF WORK:
<br /> REPLACE HEAT PUMPS ?-
<br /> THIS INSTALLATION INCLUDES THE FOLLOWING SCOPE: (SELECT ALL THAT APPLY)
<br /> LINE VOLTAGE WORK? ❑ NO Q YES-Select Scope: El Service ❑ Feeder Circuits-#11 _ ❑Complete Re-wire
<br /> LOW VOLTAGE WORK? ❑ NO 0 YES-#of Devices: _
<br /> SELECT SCOPE(REQUIRED); ❑ Data ❑ Intercom El Thermostat El Audio El Secure Access El Security System
<br /> III 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 /> El Other(List All):
<br /> ,‘"1,261004301
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<br /> IS THIS PERMIT J •'y • ,� ;,.n,�lilw%'iA'�C.:anu?FM r °r«ua�.`• �IZ.�._,""'�� .=.,�.1,..i.,++,•A". .MMr:,,.:�.,.�..�....,1"�yhfw.L��'�:�x�a1a�°.vc�"�
<br /> IT EDUCATION,INSTITUTIONAL,HEALTH AND/OR PERSONAL CARE FACILITIES: °' NO IN YES—See Below&Pg.2
<br /> r 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: ElNO •YES-See Below&Pg. 3
<br /> 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: BRUCE DIXON DDS TENANT BUSINESS NAME(If Commercial):
<br /> OWNER MAILING ADDRESS: STREET 3430 COLBY AVE
<br /> CITY EVERETT STATE WA yip 98201
<br /> OWNER PHONE:425.61.38321 OWNER EMAIL:
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<br /> CONTRACTOR NAME: EYLANDER SALES & SERVICE
<br /> CONTRACTOR ADDRESS: s1REET3601 EVERETT AVE `�'
<br /> CiTy EVERETT STATE V VA zP 98201
<br /> CONTRACTOR PHONE:425.259.2161 CONTRACTOR EMAIL:JCeylander cDyahoo.COm
<br /> CONTRACTOR LIC.#(REQUIRED);EYLANSS142LP CITY OF EVERETT BUSINESS LIG.#{REQUIRED :016363
<br /> PRIMARY CONTACT: ❑OWNER ❑CONTRACTOR QOTHER(Please Specify)
<br /> CONTACT NAME: CONTACT PHONE:425.231.2275
<br /> corny 1st CONTACT EMAIL:jCeylander©yaYtoo.com
<br /> AGREEMENT:/hereby certify that I have read and examined this application and know the same to De 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 reg I ing construction or the performance efconstruction. That/am authortzed by the owner of this property to perform the wort(for which application is made and I
<br /> comply wit State ontractors Law 18.27 RCW and 295.200 WAC, City of Everett Official Use Only
<br /> PERMIT#:
<br /> 1/7/,1 Eio?)--)2C0
<br /> O er/ uthor•.• gent Signature Date (Revised 1/11/1119) Page 1-Application
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