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ELECTRICAL PERMIT APPLICATION
<br /> CITY OF EVERETT PERMIT SERVICES
<br /> - 3200 CEDAR STREET,EVERETT,WA 98201
<br /> (P)425-257-8810 I FAX 425-257-8857 1(E)everetteps@everettwa.gov 1 www.everettwa.gov/permits
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<br /> PROJECT ADDRESS: 5122 DELAWARE AVE BUILDING AREA: 1556 sq ft
<br /> PROJECT TYPE: ❑ NEW CONSTRUCTION ❑ADDITION ❑TENANT IMPROVMENT ©REMODEL
<br /> BUILDING USE: ❑✓ SFR ❑TOWNHOUSE ❑DUPLEX El ADU ❑ MULTI-FAMILY-#OF UNITS: ❑COMMERCIAL
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<br /> CONTRACT PRICE OF WORK:$ 2511.13 ASSOCIATED BUILDING PERMIT#(if applicable):
<br /> DESCRIBE SCOPE OF WORK:
<br /> 200 AMP PANEL CHANGE
<br /> THIS INSTALLATION INCLUDES THE FOLLOWING SCOPE: (SELECT ALL THAT APPLY)
<br /> LINE VOLTAGE WORK? ❑NO ❑✓ YES-Select Scope: ✓❑Service ❑Feeder
<br /> ❑Circuits-#: ❑ Complete Re-wire
<br /> LOW VOLTAGE WORK? NO ❑YES-#of Devices:
<br /> SELECT SCOPE(REQUIRED): ❑ Data ❑ Intercom ❑Thermostat ❑Audio ❑Secure Access ❑Security System
<br /> El 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):
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<br /> IS THIS PERMIT EDUCATION,INSTITUTIONAL,HEALTH AND/OR PERSONAL CARE FACILITIES: ©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 YOUAN OWNER PERFORMING WORK AS THE CONTRACTOR WITHOUT ELECTRICAL LICENSURE: ❑NO OYES-See Below&P .3
<br /> 7 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: ADAM ANSOFF • TENANT BUSINESS NAME(If Commercial):
<br /> OWNER MAILING ADDRESS: STeeeT 5122 DELAWARE AVE
<br /> cm' EVERETT STATE WA ZIP 98203
<br /> OWNER PHONE:708-254-3412 OWNER EMAIL:
<br /> CONTRACTOR NAME: GS HEATING, COOLING & ELECTRICAL LLC
<br /> CONTRACTOR ADDRESS: STREE'r3409 EVERETT AVE
<br /> crrr EVERETT STATE WA zip 98201
<br /> CONTRACTOR PHONE:425-610-4257 CONTRACTOR EMAIL:SARA@GSHEATING.COM
<br /> CONTRACTOR LIC.#(REQUIRED):GSHEAHC8218R CITY OF EVERETT BUSINESS LIC.#(REQUIRED): 60058
<br /> PRIMARY CONTACT: DOWNER ❑✓CONTRACTOR EIOTHER(Please Specify)
<br /> CONTACT NAME: CONTACT PHONE:425-610-4257
<br /> SARA HOLLAND CONTACT EMAIL:SARA@GSHEATING.COM
<br /> AGREEMENT: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
<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 I
<br /> comply with the State Contractors Law 18.27 RCW and 296.200 WAC. City of Everett Official Use Only
<br /> PERMIT#:
<br /> -gent -al_ EWA% ‘ ' p);
<br /> Owner/Authorize enSignature Date (Revised 1/11/2019) Pagel-Application
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