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• Ur fi -ECTRICAL PERMIT APPLAkTION
<br /> EVERETT 32CITY OF EVERETT PERMIT SERVICES
<br /> 00 CEDAR STREET,EVERETT,WA 98201
<br /> WASHINGTON (P)425-257-8810 I FAX 425-2578857 (E)-everetteps@everettwa:gov l -www:everettwa.-gov/permits
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<br /> PROJECT ADDRESS: 85 g 0 ' i �10'�. - Lid sc- BUILDING AREA:
<br /> rw.3 sq ft
<br /> PROJECT TYPE: ❑NEW CONSTRUCTION ❑ADDITION [XI TENANT IMPROVMENT ❑ REMODEL
<br /> BUILDING USE: ❑SFR ❑TOWNHOUSE ❑DUPLEX ❑ADU I MULTI-FAMILY-#OF UNITS: 2-41 Cl COMMERCIAL
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<br /> CONTRACT PRICE OF WORK:$ /-j�jVv(00 ASSOCIATED BUILDING PERMIT#(if applicable):
<br /> DESCRIBE SCOPE OF WORK:
<br /> 724. GY f244 cL. QZ.e•P Leta e 6'^ -w.ti—P- "Ll k� (-tn2 Ll
<br /> THIS INSTALLATION INCLUDES THE FOLLOWING SCOPE:(SELECT ALL THAT APPLY)
<br /> UNE VOLTAGE WORK? ❑NO ❑YES-Select Scope: ❑Service CIFeeder CI Circuits-#: CIComplete Re-wire
<br /> CIy
<br /> LOW VOLTAGE WORK? NO (p.YES-#of Devices:
<br /> SELECT SCOPE(REQUIRED): ❑Data ❑Intercom ❑Thermostat El Audio ❑Secure Access Cl Security System
<br /> ❑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 /> t1 Other(List All): ?A4J - 8�
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<br /> IS THIS PERMIT EDUCATION,INSTITUTIONAL,HEALTH AND/OR PERSONAL CARE FACILITIES: NO LI YES--See Below&Pg.2
<br /> By checking this box,I am stating that I have read and understand all of WAC 296-468-90 ,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 YOU AN OWNER PERFORMING WORK AS THE CONTRACTOR WITHOUT ELECTRICAL LICENSURE:$NO DYES-See Below&Pg.3
<br /> El I 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: KE 13c2.C.-M t�42,./s0SST TENANT BUSINESS NAME(If Commercial): ''' ' e-C-1•1 &f`'rs-
<br /> OWNER MAILING ADDRESS: STREET 135 3 o ��/{-i /rte• b'r LAM'. f�
<br /> CITY 6v� STATE W • - ZIP 98ze29
<br /> OWNER
<br /> PHONEi-f 7 35' OWNER EMAIL � lb4.r1&..4/ t
<br /> CONTRACTOR NAME: /3i 1?
<br /> CONTRACTOR ADDRESS: STREET 30 13 f 3{'ct Ave Q
<br /> am, SCI/ STATE l�T�, ZIP / /v/��/
<br /> CONTRACTOR PHONE:Z04.-"Z11-17 2.1 CONTRACTOR EMAIL: /4;7�►j14. -Fi re. , Corti
<br /> CONTRACTOR LIC #(REQUIRED) i f /N 3 CITY OF EVERETT BUSINESS LIC #(REQUIRED 421 e0y
<br /> PRIMARY CONTACT: ❑OWNERCONTRACTOR ❑OTHER(Please Specify)
<br /> CONTACT NAME: CONTACT PHONE: 2E '515- - /7/6
<br /> CONTACT EMAIL: e r;k ire -�y yt r
<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!
<br /> comply with the State Contractors Law 18.27 RCW and 296.200 WAC. City of Everett Official Use Only
<br /> PERMIT#:
<br /> E )01Zlg5
<br /> Owner/Authorizednt Signature Date (Revised 1/11/2019) Page 1-Application
<br /> 3
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