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111 mils
<br /> ® ELECTRICAL PER IT A PUIC TION
<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 1 www.everettwa.gov/permits
<br /> PROJECT iTE INFORMATION
<br /> PROJECT ADDRESS: 111),i),tki, 6"---v-0,0(,1 f\1 t, E�r..,,,e I BUILDING AREA: sal ft
<br /> PROJECT TYPE: ❑ NEW CONSTRUCTION ❑ADDITION N.TENANT IMPROVMENT ❑ REMODEL
<br /> BUILDING USE: li SFR ❑ TOWNHOUSE ❑ DUPLEX ❑ADU ❑ MULTI-FAMILY-#OF UNITS: ❑ COMMERCIAL
<br /> ELECTRICAL APPLICATION INFORMATION & DESCRIPTION OF WORK
<br /> CONTRACT PRICE OF WORK:$ 3 oc) ASSOCIATED BUILDING PERMIT#(if applicable):
<br /> DESCRIBE SCOPE OF WORK: ‘:�r,-4 t...j1 C 1e-1.' i—( 4'"f � f(0 0 r' ( '( / t le\ i;tete)i I>, /n`Vv)
<br /> THIS INSTALLATION INCLUDES THE FOLLOWING SCOPE: (SELECT ALL THAT APPL
<br /> iy,(----\
<br /> LINE VOLTAGE WORK? �II��..NO ❑YES-Select Scope: ❑ Service ❑ Feeder Circuits-#: ElComplete Re-wire
<br /> LOW VOLTAGE WORK? I�-NO E YES-#of Devices:
<br /> SELECT SCOPE(REQUIRED): ElData ❑ Intercom ElThermostat ❑Audio 1] SecureAcc� ❑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: 7 NO ❑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 LICENSURELNNO 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.
<br /> CONTACT INFORMATION .
<br /> OWNER NAME: l_I.{ _, I(., \< TENANT BUSINESS NAME(If Commercial):
<br /> OWNER MAILING ADDRESS: STREET VD,0ie (7-1-'WY-Nt Al? 1}/�{��
<br /> CITY Y ki .5QIr Al- STATE \A) F ZIP 11 c ( 'VL
<br /> OWNER PHONE: la") ?113 ;)79-1c) OWNER EMAIL: I'(s � IZ,QjKfl1 C.r p •. +- C . ( ,-
<br /> CONTRACTOR NAME: '.j IX v-.,-„Q eNt;,eF�cA\ V.14 L.1,r- I C,
<br /> CONTRACTOR ADDRESS: STREET 4--;,73 L;C{ 1.1'—?'t1-N- A,`
<br /> CITY 1-V"\
<br /> �1 \e v ` -, \I' STATE )A ZIP 1( aC%
<br /> `"1--3
<br /> CONTRACTOR PHONE: Li D-5 ')3TICONTRACTOR EMAIL: ..\or B 3 d-v- ''�5\L t•�c� I 't'(' C.4'r 1L ,C.G0"1
<br /> CONTRACTOR LIC.#(REQUIRED) .3 . C�Q..- '1,- C)0 Ii C•r CITY OF EVERETT BUSINESS LIC.#(REQUIRED): i ,
<br /> PRIMARY CONTACT: ❑OWNER CONTRACTOR OTHER(Please Specify)
<br /> CONTACT NAME: CONTACT PHONE: 1I 3..3 1VD-3 QDLj 3 --1 /
<br /> J0Ni. P)i U -e-� CONTACT EMAIL: ,G,'\b€ 3 d,,�4.-,s,,,',c, •f +c( Y►_IC ,.L-C't•"1
<br /> AGREEMENT:I hereby certify that I have reicl 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 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 /> 4 Al I IT/ 10/1
<br /> Owner/Aut razed Agent Signature Date / (Revised 1/11/2019) Page 1-Application
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