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<br /> ELECTRICAL PERMIT APPLIEATION
<br /> „4 _lidrWil-_ CITY OF EVERETT ERMIT SERVICES.
<br /> 3200 CEDAR STREETPEVERETT,WA 98201
<br /> (P)425-257-8810 I FAX 425-257-8857ny� 1(E)everettyeps�@everettwa�gojv��wy-ww.everettwa gov/permits Q
<br /> t c. a y :.: .,'z .� ca E #11400T e� TE I EOR Stip l uua a� �`- 'V F�` ..... ........ ?e.,..,
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<br /> PROJECT ADDRESS: a,g 2 i 14-.c L464. R 0 e.• e ye.r`4-1 9 0-2.®k (BUILDING AREA: sq ft
<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: 0 COMMERCIAL
<br /> x e a ne TRE,CA APP?41.011 O1 I OR TIONigiVEKRI .._EOf7.,u. `"` _IRKI nat
<br /> CONTRACT PRICE OF WORK:$ ..S-Oc CPC, 'ASSOCIATED BUILDING PERMIT#(if applicable): 45 /70,3 — a© -S
<br /> DESCRIBE SCOPE OF WORK: ('1-v4,,f,'., S 0.44 -F %04-(r e s c e 6,4- I-►S k+ ti-,s -4-,., CLL n S
<br /> THIS INSTALLATION INCLUDES THE FOLLO ING SCOPE: (SELECT ALL THAT APPLY)
<br /> LINE VOLTAGE WORK? 0 NO �,YES-Select Scope:0 Service 0 Feeder 0 Circuits-#: 0 Complete Re-wire
<br /> LOW VOLTAGE WORK? 0 NO 153/Y -#of Devices:
<br /> SELECT SCOPE(REQUIRED):
<br /> 0 Data 0 Intercom 0 Thermostat 0 Audio .0 Secure Access 0 Security System
<br /> D 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 /> 0 Other(List All): L b 0 Lags I-4-. (,
<br /> s+ t :��, ecs' � y� �. CO P KNC a3�,.§� �t ' a � ` a x „e.` 'S ''� ,,..�,-plc-<.
<br /> F \0 F K S iY ` h 11 ""x rw PV AC . ._ ...,. ., x.,..I.i t,.Y'b�."1�. :: �#"..'3 3?i. �.r�
<br /> IS THIS PERMIT EDUCATION,INSTITUTIONAL,HEALTH AND/OR PERSONAL CARE FACILITIES: D NO IJ YES--See Below&Pg.2
<br /> DBy 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: O DYES-See Below&Pg.3
<br /> D 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 u, �„�� � �.�[..^t, s � '". .R M s� t d ,xix<cw;'<'1 C .R,...K.'e,x.�> dE�:�.� .:� ,..,.�uNl #a3Yh-.*.@AM�'t' �`rn.'r.sI.
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<br /> OWNER NAME: TENANT BUSINESS NAME(If Commercial):
<br /> OWNER MAILING ADDRESS: STREET
<br /> CITYSTATE ZIP
<br /> OWNER PHONE: (OWNER EMAIL:
<br /> CONTRACTOR NAME: S,Sp,.s P L�tl Tv,c /�
<br /> CONTRACTOR ADDRESS: STREET 3 7(.04.Lin oA r l.n e. U'r r• -
<br /> CITY .y-1 -%,5 4 4". - STATE ic...,/�. ZIP /Q
<br /> g�'-S
<br /> CONTRACTOR PHONE:AO*"( 7i7I_ Ls 'CONTRACTOR EMAIL:0 a r ryX4-6 C 5151,SP I,-,i,w .God
<br /> CONTRACTOR LIC.#(REQUIRED):CC i c'AIS P 19 Z LEA) CITY OF EVERETT BUSINESS LIC.#(REQUIRED): O 51,7 7..es
<br /> PRIMARY CONTACT: 0 OWNER ri CONTRACTOR 0 OTHER(Please Specify)
<br /> CONTACT NAME: CONTACT PHONE: 3 (O L 6,71 —71 4„S-
<br /> .
<br /> koy Cc 3 I <-v I A CONTACT EMAIL: 4) is,
<br /> i- .,�-s. <- _se.,349 1.44S- /11,4) r G>9 ill
<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 regulati•= •.nstruction or the performance of construction. That 1 am authorized by the owner of this property to perform the work
<br /> r for
<br /> Ewhictt Opic ai n s made and I
<br /> 400
<br /> comply with Contracto 18.27 RCW and 296.200 WAC. CitPERMIT#:
<br /> IE ) O� ' 11 I
<br /> h ,,,Z.-..---s-.. �l (Revised 1/11/2019) Page 1-Application
<br /> owner/Authorized
<br /> _d Ag 2 Signature Date
<br />
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