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•ECTRICAL PERMIT APPLIPATION <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 <br /> PROJECT SITE INFORMATION <br /> PROJECT ADDRESS:"3 53 2. OR 0A-1) JA-' VERE-Tr. 'A J BUILDING AREA:S I(AS 0 sq ft <br /> PROJECT TYPE: El NEW CONSTRUCTION ❑ADDITION El TENANT IMPROVMENT i i E C)hD IN)EC_T <br /> BUILDING USE: ❑SFR ❑ TOWNHOUSE El DUPLEX ❑ADU ❑ MULTI-FAMILY-#OF UNITS: <br /> ELECTRICAL APPLICATION INFORMATION & DESCRIPTION OF WORKo <br /> COMMERCIAL <br /> CONTRACT PRICE OF WORK:$ 8COk C 'ASSOCIATED BUILDING PERMIT#(if applicable): `'eLS (v f <br /> 6N.J) <br /> DESCRIBE SCOPE OF WORK: R .?LACE- ETC, S I(0IJ 3 1.71--1 i.J �Z L..I(a � '( <br /> C)N C rJley 2 C Ji\)EC.i M 'R to z C-40 ak (Po LE <br /> THIS INSTALLATION INCLUDES THE FOLLOWING SCOPE: (SELECT ALL THAT APPLY) <br /> LINE VOLTAGE WORK? El NO ❑YES-Select Scope: El Service ❑ Feeder Circuits-#: 4/ El Complete Re-wire <br /> LOW VOLTAGE WORK? El NO ❑YES-#of Devices: <br /> SELECT SCOPE(REQUIRED): El Data El Intercom El Thermostat ❑Audio El Secure Access El 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 /> ROther(List Alp: COhi IN1 i T TO -EAL1ST(KI G S!(orJ C,2c 1 j (2-t <br /> CODE COMPLIANCE <br /> IS THIS PERMIT EDUCATION,INSTITUTIONAL,HEALTH AND/OR PERSONAL CARE FACILITIES: JR NO El YES--See Below&Pg.2 <br /> fBy 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 YOU AN OWNER PERFORMING WORK AS THE CONTRACTOR WITHOUT ELECTRICAL LICENSURE: ENO EYES-See Below&Pg.3 <br /> flI <br /> 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. <br /> CONTACT INFORMATION <br /> OWNER NAME: TENANT BUSINESS NAME(If Commercial): <br /> OWNER MAILING ADDRESS: STREET <br /> CITY <br /> STATE ZIP <br /> OWNER PHONE: 'OWNER EMAIL: <br /> CONTRACTOR NAME: j__1 EAR(4 N D rT t4 1/J`E3—T' <br /> CONTRACTOR ADDRESS: STREET f 27J" i q -+ S r <br /> S C TY VJ A `^/ <br /> STATE �(Y A Zip c{8 ID g <br /> CONTRACTOR 2.04-) & 2-5--3100 'CONTRACTOR EMAIL: 1_I SA CASCADE-5 I GN S k CO M <br /> CONTRACTOR LIC. I4EA-'T'(4►'L 9 8 I TE 'CITY OF EVERETT BUSINESS LIC. ( I"] <br /> PRIMARY CONTACT: (DOWNER CONTRACTOR ['OTHER(Please Specify) <br /> CONTACT NAME: CONTACT PHONE: <br /> "l CF`j©�) 3`16-� 00�2 <br /> LI S A KI CONTACT EMAIL: <br /> LO S1VhlS K t'.D PV\ <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. <br /> City of Everett Official Use Only <br /> PERMIT#: <br /> 2.-2_5-- I E VIOL-1 - 59 <br /> Owner/ orized Agent Signature Date <br /> (Revised 1/11/2019) Page 1-Application <br />