12622 20TH DR SE 2019-11-15 - Laserfiche WebLink

A ELECTRICAL PERMIT APPLICATION / CITY OF EVERETT PERMIT SERVICES 3200 CEDAR STREET,EVERETT,WA 98201 (P)425-257-8810 FAX 425-257-8857 1(E)everetteps©everettwa.gov I www.everettwa.gov/permits SI.TE§INFORMATION , ,r. .'. ,ot ;,a> tt PROJECT ADDRESS: 12tCr2� Teas- N._,- (1,____ „,"P � BUILDING AREA: sq f{ PROJECT TYPE: ❑ N W CONSTRUCTION El ADDITION L�TENANT IMPROVMENT ❑REMODEL BUILDING USE: USFR ❑TOWNHOUSE ❑DUPLEX ❑ADU ❑MULTI-FAMILY-#OF UNITS: ❑COMMERCIAL *OttIPM.Watf ELECTRICAL APPLIPA ON;',INFORMATION 80).ESC,tIP nONtorMo R Czagg?,Y",teges...> CONTRACT PRICE OF WORK:$ ASSOCIATED BUILDING PERMIT#(if applicable): DESCRIBE SCOPE OF WORK: G; m� �— <<ire, \A 1A,k,cd THIS INSTALLATION INCLUDES THE FOLLOWING SCOPE: (SELECT ALL THAT APPLY) itte OLTAGE WORK? )2 NO< ❑YES:-Select Scope`❑Service ❑'Feeder ❑Circuits-#: Complete Re-wire LOWYOLTAG,E WORK?. ❑Np 7YES4ofDevices: SELECT SCOPE REQUIRED. ❑Data: ❑ Intercom Thermostat ❑Audio (. ) _. _ . ❑ ..............� ❑Secure Access ❑Security System El Fire Alarm-Installations under this permit only include electrical wiring rough-in of the system.An additional Fire Alarm Permit is required for review of device location and installation approval. Cl Other(List All): IS THISPERMIT EDUCATION,INSTITUTIONAL,HEALTHAND/OR „COM PERSONAL ( NCE ,--,� CARE FACILITIES: I�NO YES--See Below&Pg.2 ❑ 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 of this application(see next page),AND Plan Review is NOT required because I meet all of the following sub sections that do not See Page 2 require Plan Review. ARE YOU AN OWNER PERFORMING WORK AS THE CONTRACTOR WITHOUT ELECTRICAL LICENSURE: ENO EYES-See Below&Pg. 3 Ini I Pursuant to RCW 19.28.261, property owners and leaseholders cannot perform electrical work on buildings for rent,sale,or lease without the proper electrical licensing and certification,or exemption. By checking this box,lam stating that I have completed and See Page 3 signed the AFFIDAVIT on page 3 of this application to receive an exemption from this licensing/certification requirement. s},}7< i'F axis: 7 ts4,. 51 �. t . , > .,s' < .' ,.VONTIACI NFORMATION , ,,~?, 0t. s il :.c i S`i° 'MI; r i` tl OWNER NAME:; ]�yti�l{A, Xt�10 0.5 TENANT BUSINESS NAME(If Commercial): OWNER MAILING ADDRESS:, STREET 01.1,9 7/1 (� (��t� CITY � ��, ( r 1 v[CC:11 STATE ZIP OWNER PHONE:: (AD-1 — q-101 OWNER EMAIL: CONTRACTOR NAME: gs heating CONTRACTOR ADDRESS: STREET3409 everett ave cny everett STATE w ZIP 98201 CONTRACTOR PHONE:425-252-4402 CONTRACTOR EMAIL:dawn@gsheating.com CONTRACTOR LIC.#(REQUIRED):GSHEAHC8218R CITY OF EVERETT BUSINESS LIG.#(REQUIRED): 60058 PRIMARY CONTACT: DOWNER ❑✓CONTRACTOR ['OTHER(Please Specify) CONTACT NAME: CONTACT PHONE:425-252-4402 dawn weimer CONTACT EMAIL:dawn@gsheating.com AGREEMENT:1 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 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 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 comply with the State Contractors Law 18.27 RCW and 296.200 WAC. City of Everett Official Use Only PERMIT#: dawn weimer 01 �j E 'M D 3 coq Owner/Authorized Agent Signature D e (Revised 1/11/2019) Page 1-Application