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ELECTRICAL PERMIT APPLICATION
<br /> CITY OF EVERETT PERMIT SERVICES
<br /> -.y_ 3200 CEDAR STREET,EVERETT,WA 98201
<br /> (P)425-257-8810 I FAX 425-257-8857 1(E)everetteps@everettwa.gov I wwweverettwa.gov/Permits
<br /> ' `Z 'c Y. .."w lS .-; ( �T�FERAM '? RT 'a d '10.. x•> ........ .. 3�'.-r...w t... �3, ].3.,. :....,. .;..,..
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<br /> PROJECT ADDRESS: a'SZ-l:› L-e;,•-e P)Ni BUILDING AREA: sq ft
<br /> PROJECT TYPE: 0 NEW CONSTRUCTION 0 ADDITION D TENANT IMPROVMENT 0 REMODEL
<br /> BUILDING USE: 0 SFR 0 TOWNHOUSE 0 DUPLEX 0 ADU 0 MULTI-FAMILY #OF UNITS: COMMERCIAL
<br /> CIAL
<br /> MORK s, xEWIPTRI[WOI 'CATION NFOO PAOC�.a OVSPAI �+■. ._.�.�,(j�[j y�.�... .. .� . .. ...x. I
<br /> � .:�/ ��M 1R���10� :111 1� 4� G�'�� � 1.TH
<br /> CONTRACT PRICE OF WORK:$ j 00 ..OG !ASSOCIATED BUILDING PERMIT#(if applicable):
<br /> DESCRIBE SCOPE OF WORK: t 1...'c!'"1-4A<A-L. ® (2--, - 'pie-NA
<br /> - 4-4-.e Ps-r PO M Agk....(Z4OCW—r-ca e LIN) I -rc.) g. .(3t_Pe- illetv)--
<br /> THIS INSTALLATION INCLUDES THE FOLLOWING SCOPE: (SELECT ALL THAT APPLY)
<br /> LINE VOLTAGE WORK? 0 NO ( ``''YES-Select Scope: 0 Service 0 Feeder 0 Circuits-#:3 0 Complete Re-wire
<br /> LOW VOLTAGE WORK? 0 NO 0 YES-#of Devices:
<br /> SELECT SCOPE(REQUIRED):
<br /> D Data 0 Intercom 0 Thermostat 0 Audio .0 Secure Access 0 Security System
<br /> D 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 /> 0 Other(List All):'y. � �1j�
<br /> g 1Z ? S, �. %'t g `3 gQn11 cTM AIVIEA M r ~ �,'?, e MS'' 5'VhRr et..",. ;� ,
<br /> IS THIS PERMIT EDUCATION,INSTITUTIONAL,HEALTH AND/OR PERSONAL CARE FACILITIES: O YES--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 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: O DYES-See Below&Pg.3
<br /> ® 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 to receive an exemption from this licensing/certification requirement.
<br /> a .-: F '��^��: F�+� "n'"c"` ,�t'�`-,�.+h,'�'3'� ��'�it��� rtn -ate��v3.
<br /> iy iact „V', '0. T1�I vl.y�,�i}'4x��^s' r.di`�2 'f A c s,. a �:.. ...m�'e..`„L R ns :.3..x�mv,..a v..3�Y.
<br /> OWNER NAME: .edoc>`O 4 f FM 1N) Of,
<br /> (BUSINESS NAME(If Commercial):
<br /> OWNER MAILING ADDRESS: STREET y��®7 O o Le /9. -
<br /> Cm(
<br /> TE W.(/���
<br /> �.l'. STA i 1 ZIP
<br /> CITY FFFF•�����
<br /> OWNER PHONE: Z _ 9--:S OWNER EMAIL:
<br /> CONTRACTOR NAME: r ..1F-�1 S 6,N t-- ZI t .
<br /> CONTRACTOR ADDRESS: STREET Pc P � '5 � ^
<br /> STATE Com.,/A. . ' ZIP
<br /> CIT.Y�G �.,,©� ,�.� M
<br /> CONTRACTOR PHONE: � 33 52I 'CONTRACTOR EMAIL: Ce--4 I( ,,511.6041 Cb/, ` /�.°,%l_
<br /> CONTRACTOR LIC.#(REQUIRED):_ri f1/4CITY OF EVERETT BUSINESS LIC.#(REQUIRED): � ��''"
<br /> PRIMARY CONTACT: 0 OWNER VCONTRACTOR 0 OTHER(Please Specify)
<br /> CONTACT NAME: CONTACT PHONE: y2.----"7:k4-2Eks7
<br /> ..e1-111._. -- �� .,.�tCONTACT EMAIL: SI
<br /> AGREEMENT:I hereby(bycertify 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
<br /> ltype of work ocal law rregulatinill be-.costruction orht the perfoormancerof construction.gThatrant/ng of a perit does not presume to am authorized by the owner of this property to perform the work for which appliive authority to violate or cancel the cns of ation ation is made andny other tI or
<br /> City of Everett Official Use Only
<br /> comply with the.tate ontractors Law 18.27 RCW and 296.200 WAC. PERMIT#:
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<br /> E i A 6 4 -- 1 4 o I
<br /> I`,._
<br /> (Revised 1/11/2019) Page 1-Application
<br /> Owner/Authorized Agent Signa ure --- --- Date
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