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ELECTRICAL PERMIT APPLICATION EVERETT CITY OF EVERETT PERMIT SERVICES 3200 CEDAR STREET,EVERETT WA 98201 4� aa;Hcmh kP)425-257-8810 , FAX 425-257-8857 I lE i evereiteps@';overettwa.gov l www everettwa,gov/permits y�r,� PROJECT SITE INFORMATION PROJECT ADDRESS:3 ,,- / ' "`tf©L q ft BUILDING AREA: 'OO sq ft PROJECT TYPE: NEW CONSTRUCTION El ADDITION ❑TENANT IMPROVMENT jall.REMODEL BUILDING USE: E. SFR ❑TOWNHOUSE DUPLEX ❑ADU ❑ MULTI-FAMILY-It OF UNITS. _ ❑COMMERCIAL ELECTRICAL APPLICATION INFORMATION & DESCRIPTION OF,WORK CONTRACT PRICE OF WORK: $ O2O- L'7 ASSOCIATED BUILDING PERMIT#(if applicable): DESCRIBE SCOPE OF WORK: THIS INSTALLATION INCLUDES THE FOLLOWING SCOPE: (SELECT ALL THAT APPLY) LINE VOLTAGE WORK? ,0 NO 0 YES-Select Scope: Li Service El Feeder 0.Circuits-#: 0 , Complete Re-wire LI LOW VOLTAGE WORK? NO ❑YES-s;of Devices'. SELECT SCOPE(REQUIRED) 'LI Data ' fl Intercom ❑Thermostat ❑Audio ❑ Secure Access ❑ Security System LI Fire Alarm-Installations under this permit only include electrical wiring rough-in of the system.An additional Fire Alarm Permit is required for review of device location and installation approval. C Other(List All) CODE COMPLIANCE IS THIS PERMIT EDUCATION, INSTITUTIONAL, HEALTH AND/OR PERSONAL CARE FACILITIES: E NO ❑YES--See Below&Pg. 2 IBy checking this box.I am stating that I have read and understand all of WAC 296-468-900,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: ENO EYES-See Below&Pg.3 Pursuant to RCW 19.288.261,property owners and leaseholders cannot perform electrical work on buildings for rent,sale,or lease without the proper electrical ficensrng and certification,or exemption. By checking this box,I'am stating that I have completed and See page 3 signed the AFFIDAVIT on page 3 of this application to receive an exemption from this licensing/certification requirement. CONTACT INFORMATION OWNER NAME: .JC 0/f /1Cj"°�('i,, .,1+t37t TENANT BUSINESS NAME(If Commercial): OWNER MAILING ADDRESS: STREET if Z3 Z(11 ( (1,\,\,570„ CITY STA'E /1/12 ZIP76C.z) OWNER PHONE: t-iZS--Z.5Z-38'Z„ ,OWNER EMAIL: CONTRACTOR NAME: i)liO4 ,1.1dEL c CONTRACTOR ADDRESS: STREET it? •17 01/"1"/If"/(C. /9-/Y.-- CITY 9-/L �I/�j� circ `'�lY '1 '� STAT: ZIP SL.�"-.`—.3 CONTRACTOR PHONE: Z3 ({76/ CONTRACTOR EMAIL:O9/)45D/7,e/ice- y1,'c, a),27-1.(r,c,.,9,,- CONT ACTOR LIC;#(REQUIRED); P#/ - fZ CITY OF EVERETT BUSINESS LIC.#(REQUIRED): •3/-" PRIMARY CONTACT: LiOWNERTRA'CON ~�- � CTOR (�OTNER(Please Specify) CONTACT NAME:5 7-! CONTACT PHONE: (1Z5---Z5 '- C'7Ai CONTACT EMAIL: ATFZEEMEWT I 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 type of work will be completed what .• pacified herein or not, The granting of a permit does riot presume to give authority to violate or cancel the provisions of any other state or local regulating conetruotror performer? construction. That I am apthorized by the owner of is property to perform the Cwo,k�ofk forEwhich verett applicati0tfiiai mtaadensy and I cc,mply Wdt the State Cir tai t' CW and 296.200 WAC. Use PERMIT#: -� E • nor/ °rlxed Agent Signafur C fe (Revised 1/11/201 rJ) e 1,Application