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I 1.11
<br /> ni ELECTRICAL PERMIT APPLICATION
<br /> CITY OF EVERETT PERMIT SERVICES
<br /> EVERETT 3200 CEDAR STREET,EVERETT,WA 98201
<br /> WASHINGTON (P)425-257-8810 I FAX 425-257-8857 I(E)everetteps@everettwa.gov 1 www.everettwa.gov/permits
<br /> :''' � „;:,: PRCIJECTs:SITEINFORN1ATiON , . _...t.. _ M. :':':; :`
<br /> PROJECT ADDRESS: 143 fii/f- ms s, P 1,,,e_ BUILDING AREA: sq ft
<br /> PROJECT TYPE: ❑ NEW CONSTRUCTION ❑ADDITION .TENANT IMPROVMENT ❑ REMODEL
<br /> BUILDING USE: IRSFR ❑ TOWNHOUSE ❑ DUPLEX ❑ADU ❑ MULTI-FAMILY-#OF UNITS: ❑ COMMERCIAL
<br /> ELECTRICAL:APPLICATION=INFORMATION & DESCRIPTION OF_W!ORK
<br /> CONTRACT PRICE OF WORK:$ CO Ok..) ASSOCIATED BUILDING PERMIT#(if applicable):
<br /> DESCRIBE SCOPE OF WORK: C i rc,,L', \- 4, Sly w.,,,, pl.(l44f
<br /> THIS INSTALLATION INCLUDES THE FOLLOWING SCOPE: (SELECT ALL THAT APPLY)
<br /> LINE VOLTAGE WORK? ❑ NO [ Y-ES-Select Scope: ❑ Service ❑ Feeder Circuits-#: / El Complete Re-wire
<br /> LOW VOLTAGE WORK? KIO ❑YES-#of Devices:
<br /> SELECT SCOPE(REQUIRED): ❑ Data El Intercom E 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):
<br /> .;CODE COMPLIANCE,_: _.. :
<br /> IS THIS PERMIT EDUCATION,INSTITUTIONAL,HEALTH AND/OR PERSONAL CARE FACILITIES: gNO ❑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 AN OWNER PERFORMING WORK AS THE CONTRACTOR WITHOUT ELECTRICAL LICENSURE:MO EYES-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 /> ..'; ,:Ct'iN7"4C"1",:INFPRIV1AT1EN .,, ... .
<br /> OWNER NAME: Ki Ad;,,,,,,,,,, 0 If't 1.-',5 TENANT BUSINESS NAME(If Commercial):
<br /> OWNER MAILING ADDRESS: STREET u f f I j 6-41V\-VA ,%.. P L.-L._ ^^
<br /> CITY (�U-(f{f STATE U 4 ZIP ?`1102
<br /> 7 C 1[',Ci,
<br /> OWNER PHONE:_1/2J -7S(a+'7 5,p OWNER EMAIL ,, _„,, s., .w .. a ., ,„. ,_ ,,.
<br /> CONTRACTOR NAME: A-/trJA-0 r ulMtiliT E----4( At l C 114(—
<br /> CONTRACTOR
<br /> CONTRACTOR ADDRESS: STREET 2i.% 1,..). 11/4)I L S - /* il q 03
<br /> CrrY Re--1.IanSTATE LA/14 ZIP r c�
<br /> X 6,5.----.7-
<br /> CONTRACTOR PHONE: 20 is 3c, ' -t ,,, CONTRACTOR EMAIL: 1'cu,ic L Gi /C,w -e fe Lig./L c i^.
<br /> CONTRACTOR LIC.#(REQUIRED): AL-�) fl1 Ge�H(13 6 CITY OF EVERETT BUSINESS LIC.#(REQUIRED) OS (Q L/(a(
<br /> PRIMARY CONTACT: ❑OWNER CONTRACTOR ['OTHER(Please Specify)
<br /> CONTACT NAME: CONTACT PHONE: 24 --H3 "Th% J
<br /> I'`[onc_Z P-e ttir-w— CONTACT EMAIL: rcknc @ c.. c L.t e Ie(Ile ,L., r t v•i.-.
<br /> AGREEMENT:I hereby certify 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 /> 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 I
<br /> comply with the State Contractors Law 18.27 RCW and 296.200 WAC. City of Everett Official Use Only
<br /> O ed Agent Signature Date (Revised 1/11/2019) Page 1-Application
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