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• ELECTRICAL PERMIT APPLICATION( <br /> SCITY OF EVERETT PERMIT SERVICES <br /> 3200 CEDAR STREET, EVERETT,WA 98201 <br /> 1T";T <br /> (P)425-257-8810 � FAX 425-257-8857 I(E)everetteps@everettwa.gov 1 www.everettwa.gov/permits <br /> _ - <br /> pG�✓ <br /> ,, ;PROjECTSITE,INFORMATION `_' > . <br /> ; I <br /> PROJECT ADDRESS: / C700 5 c e„,,,,,i-,,, If tf.. BUILDING AREA: 43125171:7--- q f <br /> PROJECT TYPE: 0 NEW CONSTRUCTION • ADDITION IMPROENT TENANT � <br /> 'BUILDING USE: 0 SFR 0 TOWNHOUSE 0 DUPLEX 0 ADU 0 MULTI-FAMILY-#OF UNITS: 4� 'COMMERCIAL <br /> ' ELECTRICAL APPLICATION INFORMATION. . DESCRIPTION OF•woRI ';; <br /> CONTRACT PRICE OF WORK:$ 7_000 (ASSOCIATED BUILDING PERMIT#(if applicable): <br /> DESCRIBE SCOPE OF WORK: Wil✓ppt PCu:e r ( Oecli cc\ Cvt-'=��-) • 'A .,p <br /> t.^- kiC rvvv eowt ,c iel SIGN `Y,,MV. <br /> e )/fd��l <br /> 1 /� <br /> v <br /> THIS INSTALLATION INCLUDES THE FOLLOWING SCOPE: (SELECT ALL THAT APPLY <br /> 13C <br /> p Service Feeder Circuits-#: i'l Complete Re-wire <br /> LINE VOLTAGE WORK? ®NO L�YES-Select Scope: <br /> LOW VOLTAGE WORK? LINO 0 YES-#of Devices: <br /> SELECT SCOPE(REQUIRED): <br /> 0 Data 0 Intercom 0 Thermostat 0 Audio 0 Secure Access 0 Security System <br /> 0 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 /> CODE COMPLIANCR`= <br /> IS THIS PERMIT EDUCATION, INSTITUTIONAL,HEALTH AND/OR PERSONAL CARE FACILITIES: WO 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 /> rrrr���� <br /> ARE YOU AN OWNER PERFORMING WORK AS THE CONTRACTOR WITHOUT ELECTRICAL LICENSURE: M O OYES-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 /> `'.CONTACT<INFORNIATION '.. <br /> OWNER NAME: TENANT BUSINESS NAME(If Commercial): <br /> OWNER MAILING ADDRESS: STREET <br /> CITY STATE ZIP <br /> OWNER PHONE: OWNER EMAIL: <br /> CONTRACTOR NAME:WO f e S Cr) 501"- , .. J� <br /> CONTRACTOR ADDRESS: STREET i i (1;5 07 iVi /7 A /c ., � � �/`� ✓J �"` <br /> CITY e��� l /� <br /> / <br /> STATE '�/ ZIP or O o i I <br /> .. _ <br /> CONTRACTOR PHONE: 'CONTRACTO EMAIL: y <br /> ITY OF EVERETT BUSINESS LIC.#(REQUIRE Q•- O 69 1 <br /> CONTRACTOR LIC #(REQUIRE EC l�ef�°t11 E�1 a �� ,.�. .�..,. e_. ... <br /> PRIMARY CONTACT: ❑OWNS 0 CONTRACTOR 0 OTHER(Please Specify) <br /> CONTACT NAME: CONTACT PHONE: (1..\2c l 3 S'y —O6/�Q n ', <br /> /`1 Rod,I� CONTACT EMAIL: �1�1�`` Q�j Kv)e.L'tkSdl `�'t't <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 C work for <br /> Ewhicht pOp is atil n Use Only is made and I <br /> comply with the State Contractors Law 18.27 RCW and 296.200 WAC. PERMIT#: <br /> E ) ' DI� fl . . _ <br /> —ii....c.:--- (Revised 1/11/2019) Page 1-Application <br /> Owner/Authorized Agen Signature Date <br />