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UM <br /> MI ELECTRICAL PERMIT APPLICATION <br /> CITY OF EVERETT PERMIT SERVICES <br /> EVERETT 3200 CEDAR STREET,EVERETT,WA 98201 <br /> WA ,N(s';'-.<1N (P 1 425-257-8810 i FAX 425-257,-88E7 1(E)uverettees@evereltwa goy 1 WWW CV erettwo gowpoomts <br /> PROJECT SITE INFORMATION <br /> PROJECT ADDRESS: 4919 Evergreen Way BUILDING AREA: sq ft <br /> ,......., <br /> PROJECT TYPE: LI NEW CONSTRUCTION 0 ADDITION Z. TENANT IMPROVMENT L_.I REMODEL <br /> BUILDING USE: 0 SFR 0 T9ArIe 1-g—IThtiO SE El DUPLEX 0 ADU 0 MULTI-FAMILY-#OF UNITS: [ .] COMMERCIAL <br /> '1'11007 ......., 1%1CATIPti IIV4*,11ATIOW*DESCRIPP9#ACIF WORK <br /> CONTRACT PRICE OF WORK: 33,200 ASSOCIATED BUILDING PERMIT#Of applicable). <br /> DESCRIBE SCOPE OF W K: <br /> Perform electrical for in tore I branch circuits only <br /> THIS INSTALLATION INCLUDES THE FOLLOWING SCOPE:(SELECT ALL THAT APPLY) <br /> LINE VOLTAGE WORK? El NO 17 YES-Select Scope:0 Service LI Feeder El Cirouits-#: 9 C Complete Re-wire <br /> LOW VOLTAGE WORK? El NO 0 YES-#of Devices:_ <br /> SELECT SCOPE IREQUIRED): 0 Data 0 Intercom 71 Thermostat 0 Audio 0 Secure Access 0 Security System <br /> LI 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 /> El Other(List All): <br /> CODE COMPLIANCE <br /> IS THIS PERMIT EDUCATION.INSTITUTIONAL.HEALTH ANDIOR PERSONAL CARE FACILITIES: El NO 0 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 /> I--- 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: ONO DYES-See Below&Pg,3 <br /> Pursuant to ROW 19.28261,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 /> ... <br /> see pep'3 signed the AFFIDAVIT on page 3 of this application to receive an exemption from this licensingicertification requirement. <br /> %1"ErelP, CON TAc , RMATION ,,F4ikzE1J." , <br /> OWNER NAME: QFC TENANT BUSINESS NAME(If Commercial): OFC <br /> OWNER MAILING ADDRESS: smal 4919 Evergreen Way <br /> „iv Everett STATE WA ,,,- 98203 <br /> OWNER PHONE: OWNER EMAIL: <br /> CONTRACTOR NAME: Boyer Electric Co Inc <br /> CONTRACTOR ADDRESS: smerr 8119 240th St SW <br /> cny EdmondsWA <br /> STATE - 98026 <br /> CONTRACTOR PHONE: 206-367-7606 CONTRACTOR EMAIL: karen©boyerelectric.com <br /> CONTRACTOR LIC.#IREQUIRED):8OYEREC101LE CITY OF EVERETT BUSINESS LIC.IfiREQUIRED: 225147 <br /> PRIMARY CONTACT: LIOVVNER ECONTRACTOR OTHER(Please Specify) <br /> CONTACT NAME: CONTACT PHONE: 206 367-7606 <br /> Jacob Boyer CONTACT EMAIL: Jacob@boyerelectric.com <br /> AGREEMENT.I fieropy certify that I nave rend end examined this application anti know me same in be nue and correct Alt pmvisions or taws cue ofohtnees governing this <br /> type of work will be completed whether specified hereto or not The granting of a permit does not presume to give authority to'Arable or came(the provisions of any Wieser/le or <br /> 'OUP raw nagigehng construction or the performance of comtruchots That I am authorized by the owner of this property to Wenn the work for which application is made and I <br /> comply With the State Contractors Law 1a,27 fi'.CW arid 295200 WAC City of Everett Official Use Only <br /> 2 PERMIT#: <br /> II <br /> — <br /> ---,C; <br /> Ct E V:10,9 .._ <br /> Owner , It e ant S • store Date (Revised 1/f 1/2019) Page I-Application <br /> --- <br /> ..: <br /> —..„._ <br />