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03/17/2019 08: 02 3604740126 DONNELSON ELECTRIC INC #4020 P.001 /001
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<br /> ELECTRICAL PERMIT APPLICATION
<br /> CITY OF EVERETT PERMIT SERVICES
<br /> ,;,. 3200 CEDAR STREET,EVERETT,WA 98201
<br /> (P)425-257-8810 I FAX 425-257-8857 i(E)everetreps@everettwa.gov I www a rettwa gov/perms
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<br /> PROJECT ADDRESS: , 00 v A LAS A -._...., A BUILDING AREA: sq ft
<br /> PROJECT TYPE: 0 NEW CONSTRUCTION 0 ADDITION ®TENANT IMPROVMENT ,J.REMODEL
<br /> BUILDING USE: ®SFR iE.TO' NOUS 0 DUPLEX 0 ADU 0 MULTI FAMILY #OF UNITS: 0 COMMERCIAL
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<br /> CONTRACT PRICE OF WORK:$� t ebASSOCIATED BUILDING PERMIT#(if applicable):.
<br /> DESCRIBE SCOPE OF WOR: • Al i/' j . 4 It i _ •G U ' 0
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<br /> THIS INSTALLATION INCLUDES THE FOLLOWING COPE: (SELECT ALL THAT APPLY) — ..
<br /> LINE VOLTAGE WORK? ®NO FLYES-Select Scope:®Service 0 Feeder ®Circuits-#: ®Complete Re-wire
<br /> LOW VOLTAGE WORK? ®NO 51 YES-#of Devices:_l______
<br /> SELECT SCOPE(REQUIRED): fa Data ❑'Intercom 0 Thermostat 0 Audio .CI Secure Access 13 Security system
<br /> 0 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 /> ®Odle (List All):
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<br /> IS THIS PERMIT EDUCATION,INSTITUTIONAL,HEALTH AND/OR PERSONAL CARE FACILITIES. i':': NO ` YES—See Below&Pg.2
<br /> DBy checking this box,I am stating that 1 have read and understand all of WAC 296.468-900,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 OWNER PERFORMING WORK AS THE CONTRACTOR WITHOUT ELECTRICAL LICENSURE:raNO DYES-See Below&Pg.3
<br /> ® Pursuant to RCW 19.28.261,property owners and Ieaseholders 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 staling that 1 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.
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<br /> OWNER NAME: ZAN g Z4rACM0 TENANT BUSINESS NAME Commercial):
<br /> OWNER MAILING ADDRESS: STREET ��1..W 4r€ C- `- - (y
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<br /> ✓�."- 47 &VA-_ • - .. STATE ZIP /
<br /> OWNER PHONE: ( 2.6 q'7f 01 OWNER EMAiL
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<br /> CONTRACTOR NAME: )&4le, R' '1E.l .\s. '6..
<br /> CONTRACTOR ADDRESS: s-rre�' 1 3'k )U OSI^• ..Q�4�P LL Ai rg
<br /> CITY t/1../..• 1A) sTAru „ 21P t+; Z
<br /> CONTRACTOR PHONE: $. rr'(oCf c CONTRACTOR EMAIL: 80al r . - - ' w 4114 „lam
<br /> CONTRACTOR LIC.#(REQUIRED): 1,.1\ -r-e, ,. PZ CiTY OF EVERETT BUSINESS UC REQUIRED): 111 8
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<br /> PRIMARY CONTACT: D OWNER •'I .CONTRACTOR D OTHER(Please Specify) '
<br /> CONTACT NAME: pp CONTACT PHONE: 447 354- ii? -
<br /> �t L o CONTACT EMAIL: C-coNngik.>,T''%r4,s cO^`•
<br /> AGRE T.1 hereby certify that 1 have read and examined this application and know the same to he 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. 7 RCW and 296.200 WAC -...=.2ItY bf Everett Official Use Ong
<br /> PERMIT#:
<br /> 36 rr E k903 - 0C'
<br /> Own®7 ' o' • R..!'sgnature
<br /> Date (Revised 1/11/2019) "--4=' Page 1 Application
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