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ELECTRICAL OfkIVIIT & FIREALARM E I 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)everetteps@everettwa.gov www.everettwa.gov/permits
<br /> PRCIJE( T}SITE_'INFARMA 'I+OIV`
<br /> PROJECT ADDRESS:-7��1 C t4 I2.P , vv,— 'it 7-03
<br /> PROJECT TYPE: 0 NEW CONSTRUCTION 0 ADDITION WENANT IMPROVMENT 0 REMODEL
<br /> BUILDING USE: 71111.FR 0 TOWNHOUSE 0 DUPLEX 0 ADU 0 MULTI-FAMILY-#OF UNITS: 0 COMMERCIAL
<br /> BUILDING AREA: sq ft
<br /> ELECTRICAL'A!!LICATION INFQRM'ATIO'N r `�
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<br /> CONTRACT PRICE OF WORK:$ 73C0 ASSOCIATED BUILDING PERMIT#(if applicable):
<br /> IS THIS LOW VOLTAGE WORK? 0 NO 0 YES-#OF DEVICES:
<br /> IS THIS A FIRE ALARM PERMIT? 0 NO 0 YES-Plans required for review(Both Electrical and Fire Department inspections are required)
<br /> .. .... . ,DSCRIPTIQ0„bEWORK,& CODEGONI,1LrANCE N ,, ,t R1
<br /> DESCRIPTION OF WORK: Ali 0/E7 .4 A 4 �_ v ' VI-Calrti5 W L-ED
<br /> THIS SECTION APPLIES TO ALL EDUCATION,INSITUTIONAL,HEALTH AND/OR PERSONAL CARE FACILITIES:
<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 /> ATTENTION OWNERS:THIS SECTION IS FOR OWNERS PERFORMING WORK AS THE CONTRACTOR WITHOUT ELECTRICAL LICENSURE:
<br /> ❑ Pursuant to RCW 19.28.261,property owners and leaseholders cannot perform electrical work on buildings for rent,sale,or lease without
<br /> the proper electrical licensing and certification,or exemption.By checking this box,I am stating that I have completed and signed the
<br /> See Page 3 AFFIDAVIT on page 3 of this application to receive an exemption from this licensing/certification requirement.
<br /> CONTACT INFORMATION
<br /> OWNER NAME:5//f ¢,1kt A --- OENANT BUSINESS NAME(If Commercial):
<br /> OWNER MAILING ADDRESS: STREEilroa( kyillzrazits1i 2.4)
<br /> CITY STATE VV , ZIPialt 203
<br /> /1 ,�n�` p `'
<br /> O PRONE IA - VO WNER EMAIL 1• ri'1N M �6Q Qt/W
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<br /> CONTRACTOR NAME:A-f i ' ' OM-&C -
<br /> CONTRACTOR ADDRESS: STREET "15121 S E y
<br /> � ((�� CITY .� l t "1 STATE w ZIP�,�L 0b
<br /> CONTRACTOR PHONE:°4 6/M 'UOlP CONTRACTOR EMAIL: AV*N) )1/4.1e/ADE tA4&11) /I.corn
<br /> CONTRACTOR LIC.#(REQUIRED):41.11tADVIV 2 V.t,Q CITY OF EVERETT BUSINESS LIC.#(REQUIRED):L
<br /> PRIMARY CONTACT: ❑OWNER CONTRACTOR 0 OTHER(Please Specify)
<br /> CONTACT NAME: f CONTACT PHONE: 4-M- :1—7- 9(7t
<br /> M T� CONTACT EMAIL:N 'IAA �f _ A nE( A S1bM,rD M
<br /> AGREEMENT:I hereby certify that 1 have read and examined this application and know the same to be twee and correct. All provisions of laws and ordinances
<br /> 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
<br /> 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
<br /> work for which application is made and I comply with the State Contractors Law 18.27 RCW and 296.200 WAC.
<br /> City of Everett Official Use Only
<br /> PERMIT#
<br /> 1 111 - ) 0'7
<br /> Owned,uthorized Agent Signature Date (Revised 10/30/2018) Page 1 of 3
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