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`s ELECTRICAL PERMIT APPLICATION
<br /> EVERETT 32CITY OF EVERETT PERMIT SERVICES
<br /> 00 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
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<br /> PROJECT ADDRESS: S1 Oc1 2 CiN S+ 6-4e- t:II-u1A i{g?s71 BUILDING AREA: ii 64 sq ft
<br /> PROJECT TYPE: ❑ NEW CONSTRUCTION ❑ADDITION ❑TENANT IMPROVMENT N REMODEL
<br /> BUILDING USE: ❑SFR ❑TOWNHOUSE ❑DUPLEX ❑ADU ❑MULTI-FAMILY-#OF UNITS: ❑COMMERCIAL
<br /> CONTRACT PRICE OF WORK:$ Srt"!0 0 ASSOCIATED BUILDING PERMIT#(if applicable):
<br /> DESCRIBE SCOPE OF WORK: 2C.— w►.2e ctAjc.i. GLI.el x..25'"L s_elf ft'Le. p> e� ut i-Hi
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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-#: ti Complete Re-wire
<br /> LOW VOLTAGE WORK? ❑ NO ❑YES-#of Devices:
<br /> SELECT SCOPE(REQUIRED): ❑Data ❑ Intercom ❑Thermostat ❑Audio ❑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 /> ❑Other(List All):
<br /> IS THIS PERMIT EDUCATION,INSTITUTIONAL,HEALTH AND/OR PERSONAL CARE FACILITIES: • NO R 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: ONO INYES-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 Pag 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: ON ribkkan.) ' Co ' -ENI -rte TENANT BUSINESS NAME(If Commercial):
<br /> OWNER MAILING ADDRESS: STREET (13"1-1 N) Lc4, S ,rY, tin.. WIPE
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<br /> OWNER PHONE: 4',5 1 b OLt 1( (OWNER EMAIL: I✓tk -co../.dre,.Q,l—a i� I -f lvtei i L*coo
<br /> CONTRACTOR NAME:
<br /> CONTRACTOR ADDRESS: STREET
<br /> CITY _ STATE ZIP -
<br /> CONTRACTOR PHONE: (CONTRACTOR EMAIL:
<br /> CONTRACTOR LIC.#(REQUIRED): _ CITY OF EVERETT BUSINESS LIC.#(REQUIRED):
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<br /> PRIMARY CONTACT: NOWNER ❑CONTRACTOR ['OTHER(Please Specify)
<br /> CON ACT NAME: CONTACT PHONE: /12,5- -)S-0 C?`f-ic '
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<br /> AGREEMENT::I hereby certify that/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 lam 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 /> PERMIT#:
<br /> OC (A I 1C E 8 C,(/— Dcok)
<br /> O ner/ thorized Agent Signature Date (Revised 1/11/2019) Page 1-Application
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