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ELECTRICAL PERMIT APPLICATION
<br /> CITY OF EVERETT PERMIT SERVICES
<br /> 3200 CEDAR STREET,EVERETT,WA 98201
<br /> (P)425-257-8810 j FAX 425-257-8857 j(E)everetteps©everettwa.gov 1 www.everettwa.gov/permits
<br /> Oren'
<br /> "' ,a x `" ` ,PROJECT,`SITE,INFORMATION
<br /> PROJECT ADDRESS. CI f..`k'"d 1 i'YV+,/,4,-\sv.-Wt--- BUILDING AREA: sq ft
<br /> PROJECT TYPE: ❑NEW CONSTRUCTION ❑ADDITION ❑TENANT IMPROVMENT ❑REMODEL
<br /> BUILDING USE: L`J SFR ❑TOWNHOUSE ❑DUPLEX ❑ADU ❑MULTI-FAMILY-#OF UNITS: ❑COMMERCIAL
<br /> t....r. E.ELECTRICAL,APPLICATION::INFORMATION &,DESCRIPTION OF WORK„e1,, 4
<br /> CONTRACT PRICE OF WORK:$ IT 1`, ASSOCIATED BUILDING PERMIT#(if applicable):
<br /> DESCRIBE SCOPE OF WORK: 1 i,(s b 0 1` 0,'/ C�4,'1r\r;f c_ ; U7 r-.— , ii'IA t`-.) t( f r1 ^%r�(`\F;tL7 -
<br /> V/ 2 e,.., ' ,N . ,,- 7:--- 'i,i,'1.v-,9 6 J 1
<br /> THIS INSTALLATION INCLUDES THE FOLLOWING SCOPE: (SELECT ALL THAT APPLY)
<br /> LINE VOLTAGE WORK?; ❑NO ,I YES-Select Scope:111Service ❑ Feeder ❑Circuits-#: LI Complete Re-wire
<br /> r
<br /> LOW VOLTAGE WORK? ❑NO CES-#of Devices:
<br /> SELECT SCOPE(REQUIRED): ❑Data ❑ Intercom (0 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 /> ,,..,.;, 4 „t,..,nd A,, „'< i .. ., . CO,DES.,COIGIPLIANCEUV..:.,'.. ,,,. .4 OU. . UMN.,,•4S .,. ..
<br /> IS THIS PERMIT EDUCATION,INSTITUTIONAL, HEALTH AND/OR PERSONAL CARE FACILITIES: 0 NO ❑YES--See Below&Pg.2
<br /> By checking this box, I am stating that 1 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: ONO DYES-See Below&Pg.3
<br /> I1-1 I 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 /> t .,CONTACTINFORMATION u ti ,> g>
<br /> OWNER NAME: \V‘'',.\(,;7 V TiA TENANT BUSINESS NAME(If Commercial):
<br /> OWNER MAILING ADDRESS: STREEr q 61 .. k..k}0 ^y'\,rv^; n ( f (. A
<br /> Cn-r )-•ee `! STATE i M ZIP ON-7,63
<br /> OWNER PHONE: `-"l,1- -7=22, ( (Y2- OWNER EMAIL:
<br /> CONTRACTOR NAME: gs heating
<br /> CONTRACTOR ADDRESS: STREET3409 everett ave
<br /> CITY 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:425-252-4402
<br /> dawn weimer CONTACT EMAIL:dawn@gsheating.com
<br /> AGREEMENT'I hereby certify that/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 WAG City of Everett Official Use Only
<br /> PERMIT#:
<br /> dawn weimer �`� T��‘i°i
<br /> E nos - D42_
<br /> Owner/Authorized Agent Signature Date (Revised 1/11/2019) Page 1-Application
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