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<br /> it _ECTRICAL PERMIT APPL1.,ATION
<br /> EVERETT CITY OF EVERETT PERMIT SERVICES
<br /> 3200 CEDAR STREET,EVERETT,WA 98201
<br /> WASHINGTON (P)425-257-8810 I FAX 425-257-8857 1(E)everetteps@everettwa.gov I www.everettwa.gov/permits
<br /> PROJECT SITE JNFORMA ._,„ ire i`.if f�
<br /> - ,,•p..�•iii, w ..iC
<br /> PROJECT ADDRESS: ' 3 CJiE,1 Mevt. L1 ,6- l�� BUILDING AREA: 1060 sq
<br /> ft
<br /> PROJECT TYPE: El NEW CONSTRUCTION El ADDITION TENANT IMPROVMENT ❑ REMODEL
<br /> BUILDING USE: ❑SFR ❑TOWNHOUSE ❑ DUPLEX ❑ADU ❑MULTI-FAMILY-#OF UNITS: 'COMMERCIAL
<br /> ELECTRICAL: CA
<br /> ti , '�� t�RMATlOI+i°a DESCRIPTION.0F1OR_. _.: .
<br /> CONTRACT PRICE OF WORK:$ ,, k 0.. a.., ASSOCIATED BUILDING PERMIT#(if applicable):
<br /> DESCRIBE SCOPE OF WORK: l
<br /> .„„t.. .1,-,f-c,1 c ( ' . f 1
<br /> THIS INSTALLATION INCLUDES THE FOLLOWING SCOPE: (SELECT ALL THAT APPLY) `o OL-1'--d21-I
<br /> LINE VOLTAGE WORK? NO El YES-Select Scope:❑Service ❑ Feeder El Circuits-#: ❑ Complete Re-wire
<br /> LOW VOLTAGE WORK? ❑ NO BYES-#of Devices: i
<br /> SELECT SCOPE(REQUIRED): XData ❑ Intercom ❑Thermostat El Audio
<br /> ❑ Secure Access El 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 /> ❑ Other(List All):
<br /> CODE COMPLIANCE
<br /> IS THIS PERMIT EDUCATION,INSTITUTIONAL,HEALTH AND/OR PERSONAL CARE FACILITIES: NO 171 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:.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 /> CONTACTANFORM,ATI,:
<br /> OWNER NAME: t h i lit 5 r t4! I-1 TENANT BUSINESS NAME(If Commercial): T fyt,p n t¢ a,..tit A 7U
<br /> OWNER MAILING ADDRESS: STREET (p f /t4 tit, NI SIA jt,Z, 2- 0©
<br /> CITY SeA f4-(c... STATEi,A) ZIP
<br /> A 415
<br /> 106(
<br /> OWNER PHONE: Z.04 ' ( ii9 - '"'(0 1 OWNER EMAIL:
<br /> CONTRACTOR NAME: G.C . �(. �,f v C,
<br /> CONTRACTOR ADDRESS: STREET 4 T owe,f 4-u-Q, .7��1/
<br /> / .} cITV �tj(/ ASTATE ZIP g0
<br /> CONTRACTOR PHONE: /06 ILO- 3,c)(0 CONTRACTOR EMAIL: Y114 - rkIdl ), ,gc20 (1-#, C
<br /> OMA
<br /> CONTRACTOR LIC.#REQUIRED): ecLo to( 9$1�,A CITY OF EVERETT BUSINESS LIC.#(REQUIRED): 1 1 1 9
<br /> PRIMARY CONTACT: El OWNER CONTRACTOR ❑OTHER(Please Specify)
<br /> CONTACT NAME: CONTACT PHONE: 1S3 '''7.11- _ SI/3
<br /> A4.'7,fa..n1 ,A,t-1:2 1 —o CONTACT EMAIL:, j*-
<br /> AGREEMENT I herebycertify ' eAame be true
<br /> end correct.
<br /> s ns w and(d LS, c governing ti
<br /> that!have read and examined this application and know the same to be true end correct. lip visions o taws ordinance§§§ 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 c cel 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 l
<br /> comply with the ..e Contractors Law 18.27 RCW and 296.200 WAC. City of Everett Official Use Only
<br /> „..----7 PERMIT#:
<br /> __---------- a --,-q E Lor DI -op I
<br /> Owner/Aut : zed Agent Signature `-- Date (Revised 1111/2019) Page 1-Application
<br />
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