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<br /> ELECTRICAL PERMIT APPLICATION
<br /> CITY OF EVERETT PERMIT SERVICES
<br /> EVERETT 3200 CEDAR STREET, EVERETT,WA 98201
<br /> WASHINGTON (P)425-257-8810 1 FAX 425-257-8857 1(E)everetteps@everettwa.gov 1 www.everettwa.gov/permits
<br /> C � � eVPROJECT SITE INFORMATION `
<br /> PROJECT ADDRESS: �� ' OJ �,�� AZSA,\IA eliJ Int 1LDING AREA: 4-2: --, sq ft
<br /> PROJECT TYPE: El NEW CONSTRUCTION ❑ADDITION ❑TENANT IMPROVMENT ❑-REMODEL
<br /> BUILDING USE: 0 SFR ❑ TOWNHOUSE ❑ DUPLEX ❑ADU ❑ MULTI-FAMILY-#OF UNITS: ❑ COMMERCIAL
<br /> ELECTRICAL APPLICATION INFORMATION & DESCRIPTION,OF WORK
<br /> CONTRACT PRICE OF WORK:$ ,.3 �5 ASSOCIATED BUILDING PERMIT#(if applicable): %/7//—6 / /
<br /> i.DESCRIBE SCOPE OF WORK: (!)( , J I1 C9 7L La d-y' C : �c,./ ., / _ -
<br /> c4,6 () Ac)Al C,, , y- Pfl,d' 4 1 ' f L/- —-�.yc, � (:9'. .. . i e
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<br /> -- ' 'I �':i Gr z.i A - l G7T z c,',GCU''*
<br /> THIS INSTALLATION INCLUDES THE FOLLOWING SCOPE: (SELECT ALL THAT APPLY)
<br /> LINE VOLTAGE WORK? ❑ NO ..,tl YES-Select Scope: 111Service ElFeeder Circuits-#: ) CIComplete Re-wire
<br /> LOW VOLTAGE WORK? ElNO ❑4 YES-#of Devices:
<br /> SELECT SCOPE(REQUIRED): ❑ Data El Intercom ❑Thermostat El Audio El Secure Access ❑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: RANO El 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 LICENSURE: LKNO DYES-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: /:-/.5,'(^'''1',y TENANT BUSINESS NAME(If Commercial):
<br /> OWNER MAILING ADDRESS: STREET /_ /5 3 2r p/ t, SL
<br /> CITY •, C"--0-1-1(_. STATE 1-1—//4
<br /> A ZIP �/2--•
<br /> OWNER PHONE: ,:)?(')Z<-
<br /> G ,7/ Z/ 'Z OWNER EMAIL: (.G 121=' Ste`) A/41l'' ' "
<br /> CONTRACTOR NAME: ,�.NC\ M( I\ L\ \-4--)).` c\t':,Cif\(, ,\
<br /> CONTRACTOR ADDRESS: STREET L L';9 .J-) c r X 9 1 1 A�(\l-t �`- `1 l�
<br /> CITY q v-e r-- \' -, STATE )3 A ZIP 0 Q1a3
<br /> CONTRACTOR PHONE:)'\IIS - 1\ f.,'S(1• ONTRACTOR EMAIL: C c f\r-\S Jr"\C.,1 e'Nt=c ko c t\t a,\ .0 OM
<br /> CONTRACTOR LIC.#(REQUIRED) p5C,c1 CITY OF EVERETT BUSINESS LIC.#(REQUIRED? ,
<br /> PRIMARY CONTACT: .:::. O
<br /> DOWNER
<br /> � NT CTOR � �^-�. ..
<br /> ['OTHER(Please Specify) (CL 9
<br /> CONTACT NAME: CONTACT PHONE: lici. -�e5t l 3na
<br /> 1
<br /> r Pvnvf ' ' Q o n CONTACT EMAIL: C° Ir.�o,(\ct= ,� , e �
<br /> AGREEMENT:1 hereby certify that I have read and examined this application and know the same to be true and correct. All ovisions of laws and ordlnan s 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 constru bn 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 /> e CState Cont for Law 18.27 RCW and 296.200 WAC.
<br /> c City of Everett Official Use Only
<br /> PERMIT#:
<br /> .�` - ON( ICI E `dog , oQ3
<br /> Owner/Aut orized Agent gnature Date (Revised 1/11/2019) Page 1-Application
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