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<br /> ELECTRICAL PERMIT APPLICATION
<br /> CITY OF EVERETT PERMIT SERVICES
<br /> EVERETT 3200 CEDAR STREET,EVERE i I'.WA 98201
<br /> (P1425-257-8810 1 FAX 425-257-8857 1(E)everettep%©evarettwa.gov I www.everettwa.gov/pormits
<br /> WASHINGTON
<br /> 01000101.1"101101111/011110.11111WAVACSIONIMANV ; ...,, . ,..1 „ , , „
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<br /> PROJECT ADDRESS:ji2.01 al ci( ,„,,t14-60455,vi BUILDING AREA: sq ft
<br /> PROJECT TYPE: CI NEW CONSTRUCTION D ADDITION g TENANT IMPROVMENT CI REMODEL
<br /> BUILDING USE: El SFR 0 TOWNHOUSE ED DUPLEX D ADU [EI MULTI-FAMILY-#OF UNITS: 10:4 COMMERCIAL
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<br /> I_ _..,_...._....... LE"Ai - ...4:Al;'ZI:Ina AO*.! A-1.:._ ,.:).1,..* *, c 713f, 0ai,
<br /> CONTRACT PRICE OF WORK:$ /1 (1,1), .0411 ASSOCIATED BUILDING PERMIT#(if applicable):
<br /> DESCRIBE SCOPE OF WORK:
<br /> gt 1#2/A C 4 ifiW rl54110,1/41 i et.V4t it a Il T t 1 ANLI (2-t(e,e-rfrors
<br /> IS INSTALLATION INCLUDES THE FOLLOWING SCOPE:(SELECT ALL THAT APPLY)
<br /> UNE VOLTAGE WORK? 0 NOYES-Select Scope:0 Service 0 Feeder 0 CirCi cuits-#:, 1 0 Complete Re-wire
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<br /> LOW VOLTAGE WORK? 0 NO YES-#of Devices: I
<br /> SELECT SCOPE(REQQtRW ( 21a 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 /> 0 Other(List All):
<br /> IS THIS PERMIT EDUCATION,INSTITUTIONAL,HEALTH AND/OR PERSONAL CARE FACILITIES: k:i.NO III YES-See Below&Pg.2
<br /> — By checking this box,I am stating that I have read and understand all of WAC 2064613-900,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:ArNO 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 recerve an exemption from this licensing/certification requirement.
<br /> [TTT "' - - 7,1:41', d'.‘1,77".I Iffii-TOarl .. ... _. . ,
<br /> OWNER NAME: Of1/41,16&.211/1 a - ‘S Z.Z,Z, TENANT BUSINESS NAME(ff Commercial): Pti!,Va I y.
<br /> OWNER MAILING ADDRESS:
<br /> STREET 4 ii ,y- a 1
<br /> crry 4 Ile STATE a)/1/1ZIP Wir /
<br /> OWNER PHONE: 11 4/ :-g5OWNER EMAIL:
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<br /> CONTRACTOR NAME:ADDRESS: STREET
<br /> ' kiii r a- 4,8,6„0„.4.
<br /> CONTRACTOR STREET 11109 ( e,....f...
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<br /> cirY Rgelllic,fi STATE a4 z*(-? 3..37.9
<br /> CONTRACTOR PHONE:065-Yq -4. rts. COkTRACTOR EMAIL:
<br /> CONTRACTOR LIC,CREQUIRED): 8126---
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<br /> 2i
<br /> CITY OF EVERETT BUSINESS LIC.#(REQUIRED):
<br /> (D 0
<br /> x
<br /> PRIMARY CONTACT: OWNER CONTRACTOR 0THER(Please Specify)
<br /> CONTACT NAME: CONTACT PHONE: 0763-L/146-
<br /> Mtk r. 1-itiz„ CONTACT EMAIL: Mikec inc.ekthic.(do
<br /> ..
<br /> AGREEMENT:I hereby certify that I hive need and examined tAis appiicotrevt and know the same to be/ and correct. All provisions of laws and o?*Iances this
<br /> hfixt of work will be beinPleted whether specified herein or not The granting*fa permit does not presume ba give authority to viciate or cancel the provisions al any other mate or
<br /> Mod law regulating construction or the FARR)/MeitC41 of consMadion Thal I am authorized by the owner rd this property to portent)the work for which appecation is and!
<br /> empty with the State Contractors Law 18,27 RCW and 296..200 WAC. City of Everett Official Use Daly
<br /> PERMIT#:
<br /> 4( iiteff.‘/ -
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<br /> iltuthorized sent Signature Date (Revised 1/11/2019) Page 1-Applicatiori
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