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05/08/2019 13 : 14 #4194 P. 001/001
<br /> ELECTRICAL PERMIT APPLICATION
<br /> CITY OF EVERETT PERMIT SERVICES
<br /> EVERETT 3200 CEDAR STREET, EVERETT,WA 98201
<br /> WASH,I�fNGTO�,Nr ,v (P)425-257-8810 I FAX 425-257-8855771�I,(E)everetteps(�everettwagov I wwayw.ev�erettws..gov/permitssv. '-f
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<br /> PROJECT ADDRESS: 3310 HILL AVE BUILDING AREA: sq ft
<br /> PROJECT TYPE: El NEW CONSTRUCTION El ADDITION .✓❑ TENANT IMPROVMENT El REMODEL
<br /> BUILDING USE: ❑SFR E TOWNHOUSE El DUPLEX LI ADU ❑MULTI-FAMILY-#OF UNITS: E COMMERCIAL
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<br /> CONTRACT PRICE OF WORK:$ 2500 • ,
<br /> SSOCIATED T.BUILDING PERMIT#(if applicable):
<br /> DESCRIBE SCOPE OF WORK:
<br /> DISCONNECTS FOR AIR BLOWER & WATER PUMP AT425 TEST STATION
<br /> THIS INSTALLATION INCLUDES THE FOLLOWING SCOPE: (SELECT ALL THAT APPLY)
<br /> LINE VOLTAGE WORK? • ❑ NO Q YES-Select Scope: ❑Service El Feeder ✓❑Circuits-#:2 El Complete Re-wire
<br /> LOW VOLTAGE WORK? El NO E YES-#of Devices:
<br /> SELECT SCOPE(REQUIRED): ❑ Data ❑ Intercom ❑Thermostat ❑Audio El Secure Access E Security System
<br /> E] 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 /> IS THIS PERMIT EDUCATION,INSTITUTIONAL,HEALTH AND/OR PERSONAL CARE FACILITIES: ✓� NO ❑YES--See Below& Pg.2
<br /> LBy checking this box, I am stating that I have read and understand all of WAC 296.4600,selected the specific reason on page 2
<br /> of this appliB•9
<br /> cation(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 YOUAN OWNER PERFORMING WORK AS THE CONTRACTOR WITHOUT ELECTRICAL LICENSURE: ENO EYES-See Below&Pg.3
<br /> I
<br /> 7 Pursuant to RCW 19.28.261,property owners and leaseholders cannot perform electrical work on buildings for rent,safe,or lease
<br /> without the proper electrical licensing and certification,or exemption. Sy 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 /> OWNER NAME: TENANT BUSINESS NAME(If Commercial):NTNL CERT TEST LADS
<br /> OWNER MAILING ADDRESS: STREET 3310 HILL AVE
<br /> or, EVERETT
<br /> STATE WA .ro F 98201
<br /> OWNER PHONE:425.259.6799 OWNER EMAIL:
<br /> CONTRACTOR NAME: EYLANDER SALES& SERVICE
<br /> CONTRACTOR ADDRESS: sTREET3601 EVERETT AVE
<br /> cny EVERETT STATE WA zip 98201
<br /> CONTRACTOR PHONE:425.259.2161 'CONTRACTOR EMAIL:
<br /> CONTRACTOR UC.#(REQUIRED):EYLANSS142LP CITY OF EVERETT BUSINESS LIC.#(REQUIRED :016363
<br /> PRIMARY CONTACT: (]OWNER ECONTRACTOR ✓❑OTHER(Please Specify)
<br /> CONTACT NAME:MAD D R OT CONTACT PHONE:425.231.2275
<br /> CONTACT EMAIL:jceylander@yahoo.Com
<br /> ACREEM NT:I hereby certify that I have reed end examined this application and know the same to be true and conact All provisions of laws and ordinances governing this -"
<br /> type of work will be completed whether specified herein or not. The granting of a period 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 /> comet/with the State Contractors Law 18.27 RCW and 296.204 WAC. City of Everett Official Use Only
<br /> PERMIT#
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<br /> riot/A horized Agent Signature to (Revised 1N1/2019) Page 1-Application
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