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May 29 19 05:14p Bob Jack 1 6746777 p.2
<br /> ELECTRICAL PE-MIT APPLICATION
<br /> , -moi-' CITY OF EVERETT PERMIT SERVICES
<br /> 0001,--.:,_1"
<br /> 3209 CEDAR STREET,EVERETT,WA 98201
<br /> (P)425-257-8890 ] FAX 425-257-8857 1(E)everetteps@everettwa.gov I _
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<br /> PROJECT ADDRESS: /3,41)b ..\:, ...\\--K.,
<br /> .-( ,-I BUILDING AREA. sq f
<br /> PROJECT TYPE: ®NEW CONSTRUCTION El ADDITION ®TENANT IMPROVMENT UsEtf.MODEL
<br /> BUILDING USE: El SFR El TOWNHOUSE El DUPLEX 0 ADI.J ®MULTI FAMILY #OF UNITS COMMERCIAL
<br /> _-.... ,....:_;: EIEGTfz€fOiX- AP.1940417114OON19RMA'(E' €i.E11 $�
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<br /> CONTRACT PRICE OF WORK:$ 1.9.J ` 'ASSOCIATED BUILDING PERMIT#(if applicable):
<br /> DESCRIBE SCOPE OF WORK: - ,• • ,) . ) 1 1 ..,,,z- .. .,
<br /> 1' VI)ci,itkb7 11—t' c b + _p SCr"•_ i
<br /> THis INSTALLATION INCLUDES THE FOLLOWING SCOPE:(SELECT ALL THAT APPLY)
<br /> LINE VOLTAGE WORK? 0 NO ®YES-Select Scope:El Service El Feeder 0 Circuits-#: 0 Complete Re-wire
<br /> LOW VOLTAGE WORK? 0 NO YES-#of Devices: Y
<br /> SELECT SCOPE(REQUIRED): �`�
<br /> p�f,.,ata El intercom El Thermostat 0 Audio Secure Access El Security System
<br /> El 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 /> El Other(List All): _ ?,\ _ , -
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<br /> -a:...��^= .;.-�s::_ - ... ..... �::,r:: .. El YES--See Below&Pg.2
<br /> IS THIS PERMIT EDUCATION,INSTITUTIONAL HEALTH AND/OR PERSONAL CARE FACILITIES: I NO
<br /> 1:3 By checking this box,I am stating that I have read and understand all of WAC 296.461-900,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 OYES-See Below&Pg.3
<br /> El Pursuant to ROW 19.28.261,property owners and leaseholders cannot perform electrical work on b Ids gs for rent,sale,or lease
<br /> without the proper electrical licensing and certification,or exemption.By checking this box,l 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.
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<br /> OWNER NAME: Vft6 irv-e-b 64tif{f'-5 TENANT BUSINESS NAME(If Commercial): r-e,ID tt(f 1.
<br /> OWNER MAILING ADDRESS: STREET /;1 `Lf(I, BOic( ik. w4 e
<br /> CITY STATE kj ZIP g 2--) c6
<br /> OWNER PHONE: -.....OWNER EMAiL: E .... _...-......
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<br /> CONTRACTOR NAME: itVly lt (,Z ? i l: qt-e L i
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<br /> CONTRACTOR ADDRESS: STREE jam Ji T -
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<br /> MY )C Iff o1Ct STATE�;r ZIP 4 /r t <_
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<br /> CONTRACTOR PHONE: ( we J 35 (G' CONTRACTOR EMAIL: f Ig, LiAi+e6 -C 4tZe_. - C WN '
<br /> CONTRACTOR LIC.#(REQUIRED):}... ftr*�.�. `'_ '.c %g5"24-6 'CITY OF EVERETT BUSINESS LIC.#[REQUIRED):/EJ $-q 5' .. .
<br /> PRIMARY CONTACT: Ci OWNER CONTRACTOR 0 OTHER(Please Specify)
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<br /> CONTACT NAME: CONTACT PHONE: G. _n--7n-' .— c 41 L
<br /> rte` CONTACT EMAIL: . _•, i... , I P l.:l
<br /> n -typeAGREEMENT I hereby, ,d that I have p read and examined this application granting
<br /> of a know doest same p esume to give authoritylto violate or aof laws and m The prodinances visions o/angoverning er state or
<br /> oco ofla work WI om• d whetherthe speckled herein or not The granting a panauthofor which application rized reg atirig construe ••or the•: ormanco of construction. That I am by the owner of this property to perform the tykof Everett l)fficla!Use Ois n ye and t
<br /> comply with he Stara Contracfo j 19 La, 27 RCW and 296.200 WAC. PERIy11T#:
<br /> ----.4- i 1 _ _ E
<br /> '�� J i'd- `c�/r -"1 1Revised f 5 Page E-Rip iication
<br /> OwnerlAutli•rise• •gent Sign tune Date
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