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ECTRICAL PERMIT APPLI , , NCITY OF EVERETT PERMIT SERVICES
<br /> EVERETT
<br /> 3200 CEDAR STREET,EVERETT,WA 98201
<br /> WASHINGTON (P)426-257.8810 I FAX 425-257-8857 I(E)everetttyeps@everettwa,gov www,everettwa.gov/permits
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<br /> PROJECT ADDRESS: /270 3 0.A rl es live BUILDING AREA: 1 # sq ft
<br /> PROJECT TYPE: ❑ NEW CONSTRUCTION'B`ADDITION ,TENANT IMPROVMENT ❑ REMODEL
<br /> BUILDING
<br /> �1 USE: ❑SFR ❑ TOWNHOUSSE ❑ DUPLEX
<br /> {(ffry�F�❑l ADDU k o❑I MULTI-FAMILY-P#OF UNITS: (��y� yn� y COMM+�ERCIAL
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<br /> CONTRACT PRICE OF WORK:$ 30 00.OD ASSOCIATED BUILDING PERMIT#(If applicable):
<br /> DESCRIBE SCOPE OF WORK: "Ire/A4 . ,,,) roil AneN'f re54ot.A-116p1 rep14-cttpr Jt IleAivicif-9
<br /> THIS INSTALLATION INCLUDES THE FOLLOWING SCOPE: (SELECT ALL THAT APPLY)
<br /> LINE VOLTAGE WORK? ❑ NO SI YES-Select Scope:❑Service ❑ Feeder ❑Circuits-#: 3 ❑ Complete Re-wire
<br /> LOW VOLTAGE WORK? El NO Cl YES-#of Devices:
<br /> SELECT SCOPE(REQUIRED): ❑ Data ❑ Intercom El Thermostat ❑Audio ❑Secure Access El 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 /> �'. ,; {Amit' 'r P h �?!4�! N .! ` ` fie n . ',' 4441' ,
<br /> IS THIS PERMIT EDUCATION,INSTITUTIONAL, HEALTH AND/OR PERSONAL CARE FACILITIES: O 171 YES—See Below&Pg.2
<br /> By checking this box, I am stating that I have read and understand all of WAC 296-46B-90 ,selected the specific reason on page 2
<br /> EI 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 YOUAN OWNER PERFORMING WORK AS THE CONTRACTOR WITHOUT ELECTRICAL LICENSURE: 0 DYES-See Below&Pg.3
<br /> ❑ Pursuant to RCW 19.28.261,property owners and leaseholders cannot perform electrical work on b dings 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 /> g See Page 3 signed the AFFIDAVIT on page 3t of this appplic�atiion to receive an exemption yfrom thhtiiss,licensing/certification requirement. yq
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<br /> OWNER NAME: Fiba d opelf 5` TENANT BUSINESS NAME(If Commercial): ma"f},
<br /> OWNER MAILING ADDRESS: STREET Z470 3 0 ?-KGS AVe
<br /> CITY Eveg.e 4 STATE kJJ ZIP Ve I
<br /> OWNER PHONE: It . -^710 'G .6i OWNER EMAIL: SMNii:4
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<br /> CONTRACTOR NAME: PK,de Ciec-b1 C h nC
<br /> CONTRACTOR ADDRESS: STREET /V '3 ik 6121 ✓ f b -i `1�
<br /> CITY/ r,!/�Avoid r STATE �1� / ) ZIP f g° dC
<br /> CONTRACTOR PHONE: if 0'J� 4S4 '36e CONTRACTOR EMAIL: ®4 k g,. d ' . p/'t t�e�i(eC/rrl C• co-A,
<br /> CONTRACTOR LIC.#(REQUIRED): DE611"eg Nr CITY OF EVERETT BUSY ESS LIC.#(REQUIRED) 6 d ii.a
<br /> PRIMARY CONTACT: ['OWNER eXCONTRACTOR ❑OTHER(Please Specify)
<br /> CONTACT NAME: (� CONTACT PHONE: Lf p s- 't66- i of
<br /> DA('e-. QO yd CONTACT EMAIL:. ()Ale. Owl g .pi.cte elt5.f l
<br /> AGREEMENT:I hereby certify that I have read and examined this application end know the same to be true a correct.''Ail provisions of aws 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!
<br /> comply with the Ste rartortLaw 18.27 RCW and 298.200 WAC. City of Everett Official Use Only
<br /> PERMIT#:
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<br /> Owner/Authorized gent g ature ate (Revised 1/11/2019) Page 1-Application
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