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1 INN <br /> ELECTRICAL PERMIT APPLICATION <br /> EVERETT 32CITY OF EVERETT PERMIT SERVICES <br /> 00 CEDAR STREET,EVERETT,WA 98201 <br /> WASHINGTON (P)425-257-8810 I FAX 425-257-8857 1(E)everetteps@everettwa.gov 1 www.everettwa.gov/permits <br /> PROJECT ADDRESS: 70( 'BUILDING AREA: sq ft <br /> PROJECT TYPE: ❑NEW CONSTRUCTION ❑ADDITION XI TENANT IMPROVMENT ❑ REMODEL <br /> BUILDING USE: ❑SFR ❑TOWNHOUSE ❑DUPLEX El ADU ❑ MULTI-FAMILY-#OF UNITS: [g COMMERCIAL <br /> CONTRACT PRICE OF WORK:$ 00.21- ASSOCIATED BUILDING PERMIT#(if applicable): <br /> DESCRIBE SCOPE OF WORK: 3 Gorlin/ t ov,rf` mire.,/- bbloti va/ Sc ren%/. J 'Cdnnc.It — Jia4c <br /> 208 mh,4sry <br /> THIS INSTALLATION INCLUDES THE FOLLOWING SCOPE: (SELECT ALL THAT APPLY) <br /> LINE VOLTAGE WORK? ❑NO yt YES-Select Scope:❑Service ❑ Feeder El Circuits-#: ❑Complete Re-wire <br /> LOW VOLTAGE WORK? El NO P1 YES-#of Devices: 5- <br /> SELECT SCOPE(REQUIRED): ❑ Data ❑ Intercom ❑Thermostat ❑Audio El 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 /> E Other(List All): Bsie-f 7qer r,-0444 <br /> IS THIS PERMIT EDUCATION,INSTITUTIONAL,HEALTH AND/OR PERSONAL CARE FACILITIES: /:4 NO S--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 t e 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 PERFOMING WORK AS THE CONTRACTOR WITHOUT ELECTRICAL LICENSURE:RNO EYES-See Below&Pg.3 <br /> Ini I 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 towreceive an exemption from this licensing/certification requirement. <br /> OWNER NAME: c1 ,, TENANT BUSINESS NAME(If Commercial): <br /> OWNER MAILING ADDRESS: STREET 2`i3a 4t.t�/ <br /> CITY Pi/GA/I" STATE IV 7c220/ <br /> ZIP <br /> OWNER PHONE: z.c 3 29 Vi�.S1 (OWNER EMAIL: e evert/4l/t4r.OSts <br /> CONTRACTOR NAME: c, ' 4vysl <br /> CONTRACTOR ADDRESS: STREET 2 9.0 We-lrw,-e Asc. <br /> CITY Evere"..� STATE ZIP /LS'�!J <br /> CONTRACTOR PHONE: Vz3'3 2S ff f 'CONTRACTOR EMAIL:) ,c1`/@ ev,m tn.a•y. <br /> CONTRACTOR LIC.#(REQUIRED): CITY OF EVERETT BUSINESS LIC.#(REQUIRED): <br /> PRIMARY CONTACT: [OWNER ❑CONTRACTOR ❑OTHER(Please Specify) <br /> CONTACT NAME: CONTACT PHONE: L/J - 32$ Val <br /> aiS"/ il/�'� ' ��`J�6� io+ CONTACT EMAIL: Acr f e.(//.rz¢4w.el e% <br /> AGREEMENT::I hereby certify that/have red and examined this application and know the Arne 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 lam 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 /> /�� E fq1) - /74 <br /> /Authorized Agent Signature ate (Revised 1/11/2019) Page 1-Application <br />