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LLECTRICAL PERMIT APPLICATION CII Y EVERETT PERMIT SERVICES EVERETT 3200 CEDAR STREET,EVERETT,WA 98201 (P)42S-257-H10 I FAX 425-21)7-8857 i(E)evereitepsaileverettwo.goie www.ovcrettwagovipornilts WARtilr4f-TON PRoJc ITE INFO-MATSON PROJECT ADDRESS: OTPAYS0tot ivd BUILDING AREA: sq ft PROJECT TYPE: a NEW CONSTRUCTION El ADDITION LI TENANT IMPROVMENT REMODEL BUILDING USE: SFR El TOWNHOUSE 0 DUPLEX U ADU Li MULTI-FAMILY-#OF UNITS: El COMMERCIAL e:17761;:rat,ON,INFORMAT I 0 CONTRACT PRICE OF WORK:$ LOO ASSOCIATED BUILDING PERMff#(it applicable): 1,4 jo1 –OLp DESCRIBE SCOPE OF WORK: NY ria tirStAoll THIS INSTALLATION INCLUDES THE FOLLOWING SCOPE: (SELECT ALL THAT APPLY) LINE VOLTAGE WORK? E.1 NO YES-Select Scope: ri Service El Feeder KJ Circuits-#:1 El Complete Re-wire LOW VOLTAGE WORK? Ffi NO LiYES-#of Devices: SELECT SCOPE(REQUIRED): Data El Intercom Thermostat f:71 Audio El Secure Access El Security System [21 Fire Alarm-Installations under this permit only include electrical wiring rough,in of the system.An additional ire IMarm Permit is required for review of device location and Installation appruVal, " Other(List Ali COOF C ONIPL,I Afkic IS THIS PERMIT EDUCATION,INSTITUTIONAL,HEALTH-ANDIOR PERSONAL CARE FACILITIES. [4 NO YES--See Below&Pg.2 II 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 I of this application(sea next page),AND Plan Review is NOT required beCause I meet ail of the following sub sections that do not See Page 7 require Plan Review. ARE YOU AN OWNER PERFORMING WORK AS THE CONTRACTOR WITHOUT ELECTRICAL LICENSURE PNO EYES-See Below&It.3 Pursuant to ROW 19.211261.property owners arid 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 see pHge 3 signed the AFFIDAVIT on page 3 of this application to receive an exemption from this licensing/certification requirement. 41- • 111111111egift vownyirgowdi • OWNER NAME:I-M(1i_ fTkrYi Nov+ TENANT BUSINESS NAME(If Commercial OWNER MAILING ADDRESS: SrAGFT /Zip fig VC rson &Iv c:1 erne 6'W/4i-1- ZIP fl e2-01 OWNER PHONE: '-t1.4•154. )1.)U0 OWNER EMAIL: itam hairt 015 f u 1. CONTRACTOR NAME: bye 'karatki(...4th i) !i, " CONTRACTOR ADDRESS: smeer 11.1 Qt- SW.ALI rare gve„rtit STATE VA zp 59.....01 CONTRACTOR PHONE;1112•511111 Y1 CONTRACTOR EMAIL: Iin'fl) t Hit fie-Mt covvvrlort. corset CONTRACTOR Lie.fi{RLOUIREL)); 16Lo ri4 CITY OF EVERETT BUSINESS Lle.iffREQUIRLD): Lip L4 3 PRIMARY CONTACT: DOWNER SZONTRACTOR 110THER(Please Specify) CONTACT NAME: CONTACT PHONE: •1111. OtflI 1VvQ.AD CONTACT EMAIL: utel-141,7 0 11.ta.e.Y-1,64,1(1.4 Yvt r-t cort--1 AGREEMENT:I hereby certify that I hew read arid exifinfoedt awYeatiort vein detuw the.yanie to be true end awedAll ffovtginns of/awe end cir&nances governing this to of work wl ie utinpieted whether specifier,horain erect. The granting of a nerirrir does not pusarne to Ow authority to vioIate ur cancel the previsions of any other state or local fawrequitviir 0711-8EnevIOn or Me potfutrturmo of outtztruction. nut torn set/leased by the owee,r of this property ro perform the milt'for Which appitabll Is nada arid I comply with the Waie Corilrecrors Law 111.27 RCW and 2g8.200 WAC City of Everett Official Use Only PERMIT#. k5. E 90 Qid 1,3A — t'h-e-riAutherize n Signaturo Date (ReviSeri 101120(9) Page I-Application