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ELECTRICAL PERMIT APPLICATION
<br /> 41E77. CITY OF EVERETT PERMIT SERVICES
<br /> 3200 CEDAR STREET,EVERETT,WA 98201
<br /> (P)425-257-8810 I FAX 425-257-8857 i(E)everetteps@everettwa.gov I www,everettwa.gov/permits
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<br /> PROJECT ADDRESS: 1722 VIRGINIA AVE BUILDING AREA: 876 so ft
<br /> PROJECT TYPE: ❑NEW CONSTRUCTION ®ADDITION ❑TENANT IMPROVMENT ❑REMODEL
<br /> BUILDING USE: ❑SFR ❑TOWNHOUSE ❑DUPLEX ❑ADU ❑MULTI-FAMILY-#OF UNITS: ❑COMMERCIAL
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<br /> CONTRACT PRICE OF WORK:$ $12126.33 ASSOCIATED BUILDING PERMIT#(if applicable):
<br /> DESCRIBE SCOPE OF WORK:
<br /> INSTALLATION OF A DUCTLESS SYSTEM
<br /> THIS INSTALLATION INCLUDES THE FOLLOWING SCOPE: (SELECT ALL THAT APPLY)
<br /> LINE VOLTAGE:WORK? ❑NO ❑YES-Select Scope:❑Service ❑ Feeder Q Circuits-#:2 ❑Complete Re-wire
<br /> LOW VOLTAGE WORK? ✓❑NO ❑YES-#of Devices:
<br /> SELECT SCOPE(REQUIRED): ❑Data El Intercom ❑Thermostat ❑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(Ust All):
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<br /> IS THIS PERMIT EDUCATION,INSTITUTIONAL,HEALTH AND/OR PERSONAL CARE FACILITIES: E 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 LICENSURE: ✓❑NO 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,
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<br /> OWNER NAME: JAN MCCULLOCH TENANT BUSINESS NAME(If Commercial):
<br /> OWNER MAILING ADDRESS: STREET 1722 VIRGIN IA AVE
<br /> cm( EVERETT STATE WA zip 98201
<br /> OWNER PHONE:509-699-0275 OWNER EMAIL:JMCCULLOCH555@GMAIL.COM
<br /> CONTRACTOR NAME: gs heating
<br /> CONTRACTOR ADDRESS: smear 3409 everett ave
<br /> cm( everett STATE wa zip 98201
<br /> CONTRACTOR PHONE:425-610-4257 CONTRACTOR EMAIL:MELANIE@gsheating.com
<br /> CONTRACTOR LIC.#(REQUIRED):GSHEAHC8218R CITY OF EVERETT BUSINESS LIC.#(REQUIRED):60058
<br /> PRIMARY CONTACT: DOWNER ©CONTRACTOR ❑OTHER(Please Specify)
<br /> CONTACT NAME: CONTACT PHONE:425-610-4257
<br /> MELANIE MENDEHALL CONTACT EMAIL:MELANIE@GSHEATING.COM
<br /> AGREEMENT'l hereby cartify that t 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 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!
<br /> comply with the State Contractors Law 18.27 RCW and 296.200 WAC. City of Everett Official Use Only
<br /> PERMIT#: (`
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<br /> Guar.�- 14,1e`,/ 1J,j /hh'0d--0 E 2s1:0 -03(--(k
<br /> Owner/Authorized Agent Signature Date (Revised 1/11/2019) Page 1-Application
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