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ELECTRICALMIT CITY OFOF E ALARM PE MIT APPLICATION EVERETT PERMIT SERVICES 3200 CEDAR STREET, EVERETT,WA 98201 (P)425-257-8810 1 FAX 425-257-8857 1 (E)everetteps@everettwa.gov I www.everettwa.gov/permits PROJECT SITE INFORMATION PROJECT ADDRESS: 1 —_-- PROJECT TYPE: 0 NEW CONSTRUCTION LTJ ADDITION 0 TENANT IMPROVMENT 0 REMODEL BUILDING USE: ❑SFR 0 TOWNHOUSE 0 DUPLEX 0 ADU 0 MULTI-FAMILY-#OF UNITS: ❑COMMERCIAL, BUILDING AREA: sq ft ELECTRICAL APPLICATION INFORMATION CONTRACT PRICE OF WORK:$ ' cg p O ASSOCIATED BUILDING PERMIT#(if applicable): IS THIS LOW VOLTAGE WORK? ❑ NO 0 YES-#OF DEVICES: IS THIS A FIRE ALARM PERMIT? 0 NO 0 YES-Plans required for review(Both Electrical and Fire Department inspections are required) DESCRIPTION OF WORK & CODE COMPLIANCE DESCRIPTION OF WORK: k 11b A t K 1 IJ P e C c rp (�, e IS THIS PERMIT EDUCATION,INSITUTIONAL,HEALTH AND/OR PERSONAL CARE FACILITIES: 131 NO 0 YES--See Below&Pg.2 ® 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 of this application(see next page),AND Plan Review is NOT required because I meet all of the following sub sections that do not See Page 2 require Plan Review. ARE YOU AN OWNER PERFORMING WORK AS THE CONTRACTOR WITHOUT ELECTRICAL LICENSURE: ONO 137YES-See Below&Pg.3 ❑ Pursuant to RCW 19.28.261,property owners and leaseholders cannot perform electrical work on buildings for rent,sale,or lease without the proper electrical licensing and certification,or exemption.By checking this box,I am stating that I have completed and signed the See Page 3 AFFIDAVIT on page 3 of this application to receive an exemption from this licensing/certification requirement. CONTACT INFORMATION OWNER NAME: tki\V: 1(Z. ' . C, I-U M P TENANT BUSINESS NAME(If Commercial): OWNER MAILING ADDRESS: STREET ")) 1 4a 0 y F1 pi c 1- 1Ned J G Q -T "T CITY STATE ZIP CP CJ OWNER PHONE: 2 S 3 ) 61 0 2 1 `7 OWNER EMAIL: CONTRACTOR NAME: M '<Lk/Cl L e C--v-t' C L L CONTRACTOR ADDRESS: STREET ) I I C �.vk 4 C r () �'p �. t CITY - - STATE _`i, ZIP 2,0 (� . CONTRACTOR PHONE: 9 2.5" 3 'f 6 `-I 6 4'((CONTRACTOR EMAIL: CONTRACTOR LIC.#(REQUIRED): va.ki A £ L 63 i tJ 13 TY OF EVERETT BUSINESS LIC.'#(REQUIRED): / t 0: l 6 PRIMARY CONTACT: WNER 0 CONTRACTOR 0 OTHER(Please Specify) , 0 � C�O26 CONTACT NAME: CONTACT PHONE: Lk ZS II pa/-7 CONTACT EMAIL: AGREEMENT:I hereby certify that/have read and examined this application and know the same to be true and correct. All provisions of laws and ordinances governing this 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 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 comply with the State Contractors Law 18.27 RCW and 296.200 WAC. City of Everett Official Use Only PERMIT# .�%_. o 11611161/ HDI " 02/S OiiO gent Signature Date (Revised 11/5/2018) Page1_Application