Laserfiche WebLink
111 EMI <br /> EL ECT1 ICAL PERMIT APPLICATION <br /> CITY OF EVERETT PERMIT SERVICES <br /> EVERETT 3200 CEDAR STREET,EVERETT,WA 98201 <br /> WASHINGTON (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: 1113 0 142GL(i ✓e_- BUILDING AREA: sq ft <br /> PROJECT TYPE: ❑ NEW CONSTRUCTION ❑ADDITION M TENANT IMPROVMENT ❑ REMODEL <br /> BUILDING USE: XSFR ❑ TOWNHOUSE ❑ DUPLEX ❑ADU ❑ MULTI-FAMILY-#OF UNITS: ❑ COMMERCIAL <br /> ELECTRICAL APPLICATION INFORMATION & DESCRIPTION OF WORK <br /> CONTRACT PRICE OF WORK:$ O° ASSOCIATED BUILDING PERMIT#(if_ applicable): <br /> DESCRIBE SCOPE OF WORK: j/ck t2 S �7 rr -pkc i4( �L /rn fir/ L ctf I'P/t <br /> /l/ Yf F:irefl <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? El NO ❑YES-#of Devices: <br /> SELECT SCOPE(REQUIRED): ❑ Data ❑ Intercom ❑Thermostat ❑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): <br /> CODE COMPLIANCE <br /> IS THIS PERMIT EDUCATION, INSTITUTIONAL,HEALTH AND/OR PERSONAL CARE FACILITIES: ❑ NO ❑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: ENO ❑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. <br /> CONTACT INFORMATION . <br /> OWNER NAME: DIC D 11t4 per' TENANT BUSINESS NAME(If Commercial): <br /> OWNER MAILING ADDRESS: STREET I 30 &cc.k z/ AV <br /> I CITY t:✓�/a STATE ZIP 47 <br /> OWNER PHONE: ('I 25 — �6 3_Q 570 OWNER EMAIL: <br /> CONTRACTOR NAME: L-16211(.25 S -e,� �l G <br /> CONTRACTOR ADDRESS: STREET 737 LSA/ " 7!fi /1/1/1"/ // a C/ <br /> C —7 CITY /tc. L�./® 'STATE ✓ ZIP <br /> CONTRACTOR PHONE: Lj"L5-7�0-q51 CONTRACTOR EMAIL: C.1(4 k 5 e c,/rr l c g i'(4 r l • C-Pri <br /> CONTRACTOR LIC.#(REQUIRED): CLisiRK Et c 3?K ! CITY OF EVERETT BUSINESS LIC.#(REQUIRED): 53 5-06- <br /> PRIMARY <br /> -0gPRIMARY CONTACT: 4OWNER ❑CONTRACTOR ❑OTHER(Please Specify) q <br /> CONTACT NAME: CONTACT PHONE: L/Z 2—.63 S Q� 6 <br /> �C� k ( gau YJ,e I 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 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 properly to perform the work for which application is made and I <br /> comply with the State Contractors Law 18.27 RCW and 296.200 WAC. City of Everett Official Use Only <br /> PERMIT#: <br /> -v-?7/5 E - Oc5, <br /> ner/Authorized Agent Signature Date (Revised 1/11/2019) Page 1-Application <br />