|
F
<br /> 1 am
<br /> LI ELECTRICAL PERMIT APPLICATION
<br /> CITY OF EVERETT PERMIT SERVICES
<br /> EVERETT 3200 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
<br /> PROJECT ADDRESS: 4 0 3 c(v 'Thit gIVD,. BUILDING AREA: sq ft
<br /> PROJECT TYPE: ❑ NEW CONSTRUCTION ❑ADDITION El TENANT IMPROVMENT &REMODEL
<br /> BUILDING USE: KSFR ❑TOWNHOUSE LI DUPLEX ❑ADU ❑MULTI-FAMILY-#OF UNITS: ❑COMMERCIAL
<br /> R iLFVR\ ' i -LI,z av`:. 4,;_,_A�F,,r,a 1419.r.:S.L :114. ^ ", itli t. e...... tsa�i.. 9e Rr.
<br /> CONTRACT PRICE OF WORK:$ .3.-a-a- ASSOCIATED BUILDING PERM #(if applicable):
<br /> DESCRIBE SCOPE OF WORK: / g 4%1( Z41lU V cowl 1 f r r 0-4-clA,vr
<br /> •
<br /> THIS INSTALLATION INCLUDES THE FOLLOWING SCOPE: (SELECT ALL THAT APPLY)
<br /> LINE VOLTAGE WORK? Cl NO ,► YES-Select Scope:❑Service ❑Feeder ❑Circuits-#: �- ❑Complete Re-wire
<br /> LOW VOLTAGE WORK? ❑ NO ❑YES-#of Devices:
<br /> SELECT SCOPE(REQUIRED): ❑Data ❑ Intercom ❑Thermostat ❑Audio ❑Secure Access El 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 /> e
<br /> IS THIS PERMIT EDUCATION,INSTITUTIONAL,HEALTH AND/OR PERSONAL CARE FACILITIES: ,=0,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,s-lected 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: Q O DYES-See Below&Pg.3
<br /> El I I Pursuant to RCW 19.28.261,property owners and leaseholders cannot perform electrical work on buildi gs 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 application3to receive an exemption from this licensing/certification requirement y
<br /> vi n: .. ,. ' 4 „* t''.$,* .! °.,t":b.?,:',,aNN..,,F� �.e i«
<br /> ..k.,4 ,,. t'; i.'�, e ,, , '';, ;".�. ,�`. .�s7
<br /> OWNER NAME: IC a, tali GL TENANT BUSINESS NAME(If Commercial):
<br /> OWNER MAILING ADDRESS: STREET 4114rd Rt vV-/iht'/ D I D
<br /> CITY F./-GCe-- STATE , J - ZIP
<br /> OWNER PHONE: 7f' GI7.5-'58 (OWNER EMAIL:
<br /> CONTRACTOR NAME: M f 6 ,51 d
<br /> CONTRACTOR ADDRESS: STREET. 1 1 / '7 7 7 �4 02 Nf'�
<br /> CITY el SJ I ((_ STATE ZIP "8`")V
<br /> CONTRACTOR PHONE: 1115 7&O 4(1/7 I CONTRACTOR EMAIL: /145 c-el •c-iic )NAC' ' I . Co on
<br /> CONTRACTOR LIC.#(REQUIRED): $ eLeLlc '. D -.
<br /> CITY OF EVERETT BUSINESS LIC.#(REQl71RED) ,c9` '-. 'L
<br /> PRIMARY CONTACT: `,.T41 OWNER ['CONTRACTOR ['OTHER(Please Specify)
<br /> CONTACT NAME: CONTACT PHONE: 1-f t''.? 7 , ® (p ( '-{
<br /> d' " ' �� crd.tn- 0,'d CONTACT EMAIL:
<br /> AGREEMENT:!hereby certify that I 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 complete. hether 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 constr »nor the performance of construction. That t am authorized by the owner of this property to perform the work for which application is made and I
<br /> comply with the State C' -ctors Law 18�. I4CW and 96.200 WAC. City of Everett Official Use Only
<br /> PERMIT#:
<br /> ''----M ) /
<br /> _ � E Zoo( -- .(1Q IA
<br /> (Revised 1/11/2019) Pae 1-A lication
<br /> OwnerlAuthoriz=. Agent Signature- Date g PP
<br />
|