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ELECTRICAL PERMIT APPLICATION
<br /> /1111P•107 ,--4- CITY OF EVERETT PERMIT SERVICES
<br /> 3200 CEDAR STREET,EVERETT,WA 98201
<br /> (P)425-257-8810 l FAX 425-257-8857 l(E)everetteps@everettwa.gov I www.everettwa.gov/permits
<br /> INFORMATION ,
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<br /> sq ft
<br /> PROJECT ADDRESS: :,,%^', '` 1(-1�;�,�;����� ,� �{.,_�_ � BUILDINGAREA: u, , s 5• , `'
<br /> PROJECT TYPE: ❑NEW CONSTRUCTION Li ADDITION El TENANT IMPROVMENT ,REMODEL
<br /> BUILDING USE: LS SFR ❑TOWNHOUSE ❑DUPLEX ❑ADU ❑ MULTI-FAMILY #OF UNITS: ❑COMMERCIAL
<br /> 4 ,.4.'',.EL`ECTRicAL APPLICATION'INFORMATIONk&PDESCRIPTION'OF.'WORKst" r ,t„
<br /> CONTRACT PRICE OF WORK:$
<br /> 'v : 3 3 ASSOCIATED BUILDING PERMIT#(if applicable):
<br /> DESCRIBE SCOPE OF WORK: \"
<br /> a fi i'71rf 4S v V,11,?
<br /> THIS INSTALLATION INCLUDES THE FOLLOWING SCOPE: (SELECT ALL THAT AP:
<br /> LINE VOLTAGE WORK? ❑NO ,/❑AYES-Select Scope: ❑Service CI CICircuits #: ❑Complete Re-wire
<br /> c
<br /> LOW VOLTAGE WORK? LZ NO ❑YES-#of:Devices: j
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<br /> SELECT SCOPE(REQUiRED):'E Data ❑Intercom ❑Thermostat ❑`Audi` ❑Secure Access Security System
<br /> N
<br /> ❑Fire Alarm-Installations under this permit only include a trical wiring rough the system.An additional
<br /> Fire Alarm Permit is required for review of device location and ins - '_• -.. oval.
<br /> ❑ Other(List All):
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<br /> IS THIS PERMIT EDUCATION,INSTITUTIONAL,HEALTH AND/OR PERSONAL CARE FACILITIES: LI NO LYES-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. �i
<br /> ARE YOU AN OWNER PERFORMING WORK AS THE CONTRACTOR WITHOUT ELECTRICAL LICENSURE: ✓❑NO EYES-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.
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<br /> CONT°, a �,,.. A� ,
<br /> OWNER NAME: ,\jam.1/1 i r' \Itir,E;1'it - TENANT BUSINESS NAME(If Commercial):
<br /> OWNER MAILING ADDRESS: STREET LA t(.3S: ti
<br /> cry a,%VC..JII, STATE LN ZIP ef :
<br /> OWNER PHONE:f r) -`x-51— p7 OWNER.EMAIL:
<br /> CONTRACTOR NAME: gs heating
<br /> CONTRACTOR ADDRESS: STREET 3409 everett ave
<br /> crry everett STATE wa zip 98201
<br /> CONTRACTOR PHONE:425-252-4402 CONTRACTOR EMAIL:dawn@gsheating.com
<br /> CONTRACTOR LIC.#(REQUIRED):GSHEAHC8218R CITY OF EVERETT BUSINESS LIC.#(REQUIRED): 60058
<br /> PRIMARY CONTACT: EOWNER ❑✓CONTRACTOR ❑OTHER(Please Specify)
<br /> CONTACT NAME: CONTACT PHONE:425-252-4402
<br /> dawn we i m e r CONTACT EMAIL:dawn@gsheating.com
<br /> AGREEMENT:I hereby certify that!have read and examined this application and know the same to be true and correct. A!!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 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 /> dawn r > E DO
<br /> ��(
<br /> Ownn (Authorized Agent Signature Date (Revised 1/11/2019) Page 1-Application
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