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A0141P—
<br /> ,....9^ ELECTRICAL PERMIT APPLICATION
<br /> 44711rrif3200 CEDAR STREET,EVERETT,WA 98201
<br /> (P)425-257-81310 I FAX 425457-m57 I(El ovorettaplatovortittwa.gov I www.uverettwa.govipermits
<br /> Gin'OF EVERETT PERMITSERVICES:
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<br /> PROJECT ADDRESS:91.14 e Di/V/1'99S 'BUILDING AREA: i'00(6) sq ft
<br /> PROJECT TYPE: LI NEW CONSTRUCTION D ADDITION El TENANT IMPROVMENT Ei REMODEL
<br /> BUILDING USE: j2(SFR 0 TOWNHOUSE El DUPLEX 0 ADU El MULTI-FAMILY-#OF UNITS: El COMMERCIAL
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<br /> CONTRACT PRICE OF WORK:$ 14 1)0 ASSOCIATED BUILDING PERMIT#(if applicable):
<br /> DESCRIBE SCOPE OF WORF1'.j-' (....-V 174Loj... H6 -r Juin yr4ALpjga:___,
<br /> THIS INSTALLATION INCLUDES THE FOLLOWING SCOPE: (SELECT ALL THAT APPLY)
<br /> LINE VOLTAGE WORK? El NO ,,171YES-Select Scope: 117]Service 0 Feeder LaCircuits-#: I E Comploto Ro.wire
<br /> LOW VOLTAGE WORK? 0 NO El YES-4 c_sf Devices;
<br /> SELECT SCOPE(REQUIRED). 0 Data El intercom 7rThemiustat El Audio 0 Secure Access El Security System
<br /> III Fire Nam-Installations under this permit only include electrical wiring mugh-In of the system.An additional
<br /> Fire Alarm Permit is required for review of device location and installation approval.
<br /> ,j2)Other(List All): t4eltk'M;01,19
<br /> ''i'.'t•'*N.,•'eiiiii,T; '-',:,•';':':4277771kiYaitairMiriria7,,!,.,:,:. ,f,'‘. PE',4');Tr''.t' AP ,',i.iV".t.IN.,;„;„.,-',...: 11774: 2',
<br /> IS THIS PERMIT EDUCATION,INSTITUTIONAL,HEALTH AND/OR PERSONAL CARE FACILITIES: Till NO ill YES--See Below&Pg.2
<br /> LI 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: NO DYES-See Below&Pg,3
<br /> fl Pursuant to RCW 19.28.281,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 licensingkertification requirement.
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<br /> OWNER NAME: ci0341414Ntri-pi(),A,' TENANT BUSINESS NAME(If Commercial):
<br /> OWNER MAILING ADDRESS: SWIM'9 )4 .1)1/411/194)3 k AO.
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<br /> CllY :1 - WF., WA AP CP82.6)
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<br /> OWNER PHONE; -C}') €3 161 CO(I? OWNER EMAIL: Ofit t4 NI A,PAE,S a-)"film G, coin
<br /> CONTRACTOR NAME: N--V 0- Pt/141 i-i-eAT i IV 6 VAI i2.
<br /> CONTRACTOR ADDRESS: smEET -i-flI'k .) -1-2-0-r-a RT iv 44.---1
<br /> ,:o. A4 1:7STATE irA.44 ZIP ei 00143
<br /> CONTRACTOR PHONE: 41.0 Ti ,i,
<br /> V1-1.3) 1NR)41 CONTRACTOR EMAIL: IV 13010P1441E-6§111AT:
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<br /> CONTRACTOR C.41(REOUIRED):t,Lk)FVF 4-4 1 12+'--- CITY OF EVERETT BUSINESS LIC.*REQUIRIED): III2.9'41 Cl
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<br /> PRIMARY CONTACT; DOWNER j2e0NTRACTOR DOTHER(Please Specify) ....
<br /> ....
<br /> CONTACT NAME: 'CONTACT PHONE:l4;2
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<br /> CONTACT EMAIL:!NH 3 uoivrulmechtripor2--r.c6ryi
<br /> tIGREEMEINIT:I hereby certify that I have read'and examined tide appkation and know the sate to be tree and correct. AS protoisiorm of laws end ordirtenees governing tills
<br /> We of YAW(WAS be completed whether sneaked herein or rroL The granting of a permit does not presume to give authority to violate or cancel the provisions of any other state or
<br /> bast few regulating construotton ar the padermanee of eanstructien That I am authorized by the owner of Iris property to perform the work for which aoulteatkm is mode end)
<br /> comply with If to Stale Contractors Law 18.27 RCW end 296.200 WAC. City of Everett Official Use Only
<br /> PERMIT#:
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