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1 11111111N
<br /> m ELECTRICAL 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 wnnv.everettwa.gov/permits
<br /> PROJECT SITE INFORMATION
<br /> PROJECT ADDRESS: 13143 N O --t �,', r
<br /> i �-BUILDING AREA: � i sat St
<br /> PROJECT TYPE: ❑ NEW CONSTRUCTION ❑ADDITION - 'l TENANT IMPROVMENT ❑REMODEL �-1
<br /> BUILDING USE: J SFR El TOWNHOUSE El DUPLEX 171 ADU 171MULTI-FAMILY-#OF UNITS: ❑ COMMERCIAL
<br /> ELECTRICAL APPLICATION INFORMATION & DESCRIPTIO. OF WORD
<br /> CONTRACT PRICE OF WORK:$ 13 S 0 0 ASSOCIATED BUILDING PERMIT#(if applicable):
<br /> DESCRIBE SCOPE OF WORK: f.,F N.vatre, 1.-v7 c,5p / N ', .c-' ,/ \ ---
<br /> THIS INSTALLATION INCLUDES THE FOLLOWING SCOPE: (SELECT ALL THAT APPLY)
<br /> LINE VOLTAGE WORK? XNO ❑YES-Select Scope:-Service ❑ Feeder ❑ Circuits-#: RComplete Re-wire
<br /> LOW VOLTAGE WORK? -II NO ❑YES-#of Devices:
<br /> SELECT SCOPE(REQUIRED): ❑ Data El 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: '7-NO El 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:-T1NO EYES-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: r' - v-t ( k P C `-) TENANT BUSINESS NAME(If Commercial):
<br /> OWNER MAILING ADDRESS: STREET r 0-2->" .-2->" .,(1 �r^� A�,r z„
<br /> CITY �^SL ..Y�( \1 STATE \,,
<br /> I,) ZIP 1J :,. r>)(- O
<br /> OWNER PHONE: 9.2 .S3``,„ t 7-5`1 OWNER EMAIL: P , PCk €. (_ , ,,, E ,,,d. : > ){ 4,
<br /> CONTRACTOR NAME: "3 D r-rN. tl S,enc\ 1 g-C CCf r-t (_�-
<br /> CONTRACTOR ADDRESS: STREET 4:7- 0 4 ill k " rIQ N ,
<br /> CITY f �cAr -s -.l , I C \+'V7l!y 1 STATE V) fi ZIP 4.
<br /> CONTRACTOR PHONE: 1-1 ,5 q. __. te-IVICONTRACTOR EMAIL: -Sciv.h 3 CI,r ehS, ..,,,I(lid,r _ . Co f---) /-<--
<br /> CONTRACTOR LIC.#(REQUIRED) '3 ii% rv�� Q C� N(
<br /> 11 1 - CITY OF EVERETT BUSINESS LIC.#(REQUIRED):
<br /> PRIMARY CONTACT: ❑OWNER_PONTRACTOR ❑OTHER(Please Specify)
<br /> CONTACT NAME: t CONTACT PHONE: L'� 4:3e-6 3 1' )
<br /> ®tri g v \) CONTACT EMAIL: -
<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 WAC. City of Everett Official Use Only
<br /> PERMIT#:
<br /> , „ 4 i
<br /> 1.0/4 , c(/ E \.9 c0 — 0(lo 2-
<br /> Own•r/Authorized Agent Signature Date (Revised 1/11/2019) Page 1-Application
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