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<br /> E CTRICAL PERMIT APPLIitiTION
<br /> EVERETT CITY OF EVERETT PERMIT SERVICE
<br /> 3200 CEDAR STREET,EVERETT,WA 98201
<br /> WASHINGTON (P)425-257-8810 1 FAX 425-257-8857 1(E)everetteps@everettwa.gov I www.everettwa.gov/permits
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<br /> PROJECT ADDRESS: ) �E- l�Vr2 ��� t 0 6p q BUILDING AREA: ' >5 'il sq ft
<br /> PROJECT TYPE: ❑ NEW CONSTRUCTION ❑ADDITION ❑TENANT IMPROVMENT KREMODEL
<br /> BUILDING USE: ❑ SFR ❑TOWNHOUSE [j❑ DUPLEX ❑ADU ❑ MULTI-FAMILY ^�-#OF UNITS:$$ 71 COMMERCIAL
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<br /> CONTRACT PRICE OF WORK:$ Z Svcs - — ASSOCIATED BUILDING PERMIT#(if applicable):
<br /> DESCRIBE SCOPE OF WORK: Lk f t aL V--E P C"YGesp-ey. c F Tttz=' ft C-6
<br /> A(i 6-C--n, Priv i. ; 0 sA G t..) 71 L.3 Sv( e
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<br /> THIS INSTALLATION INCLUDES THE FOLLOWING SCOPE: (SELECT ALL THAT APPLY)
<br /> • LINE VOLTAGE WORK? ❑ NO ❑ YES-Select Scope: ❑ Service ❑ Feeder ❑ Circuits-#: ❑ Complete Re-wire
<br /> LOW VOLTAGE WORK? ❑ NO ❑ YES-#of Devices:
<br /> SELECT SCOPE(REQUIRED): ❑ Data El Intercom ❑Thermostat El Audio ❑ Secure Access ❑ Security System
<br /> E. ire Alarm-Installations under this permit only include electrical wiring rough-in of the system.An additional
<br /> ire Alarm Permit is required for review of device location and installation approval.
<br /> n Other(List All):
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<br /> IS THIS PERMIT EDUCATION,INSTITUTIONAL,HEALTH AND/OR PERSONAL CARE FACILITIES: NO U 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 LICENSURE6ON-0—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 /> OWNER NAME:f fr eeg( 06, c _o G:S TENANT BUSINESS NAME(If Commercial): rG,L TOA S 62-0)1/4 6
<br /> OWNER MAILING ADDRESS: STREET//e, ,- 5e (, S % o
<br /> CITY /J 6-�CVac': STATE ZIP 9 O Q6
<br /> OWNER PHONE:z — 21 s-- 9 7 0 ö OWNER EMAIL:
<br /> CONTRACTOR NAME: EA-G( j(G- ('i( E Gtr
<br /> CONTRACTOR ADDRESS: STREET ' 2-0 PO?(4 pc.. 5 -
<br /> CITY 5 ri Al/ t.E STATE ZIPS g r Yv1
<br /> •
<br /> CONTRACTOR PHONE:'Z-4 j i( CONTRACTOR EMAIL: �O e)'(•j,/( 7 Q7-C( f✓d C,. f l e-C S z R (T1`( ,.C-4 "
<br /> CONTRACTOR LIC.#(REQUIRED): f{ ' ,j F f 591 ( (f' ly\ j CITY OF EVERETT BUSINESS LIC.#(REQUIRED): el 2 /s--[
<br /> PRIMARY CONTACT: ]OWNER [CONTRACTOR ❑OTHER(Please Specify)
<br /> CONTACT NAME: CONTACT PHONE: lid ,- I-- ,/ /{f
<br /> ./0-eE 'el you CONTACT EMAIL: 6 letfV e (/�!G 7 ��� t 1`E)
<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 RC and 296.200 WAC. City of Everett Official Use Only
<br /> PERMIT#:
<br /> / E /q07- 173
<br /> Owner uthorized Agen S':•• ure Date (Revised 1/11/2019) Page 1-Application
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