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• <br /> ELECTRICAL PERMIT APPLICATION <br /> CITY OF EVERETT PERMIT SERVICES <br /> EVERETT 3200 CEDAR STREET,EVERETT,WA 98201 9- <br /> WASHINGTON (P)425-257-8810 I FAX 425-257-8857 I(E)everetteps@everettwa.gov I www.everettwa.gov/permits C. 17 L)L ,3 <br /> • <br /> PROJECT;;SITE:INFORMATION .'.< <br /> PROJECT ADDRESS i t2 Jry C ����i; r, f BUILDING AREA: 9. i/6-) (, sg ft <br /> PROJECT TYPE: IJ NEW CONSTRUCTION ❑ADDITION ❑ TENANT IMPROVMENT ❑ REMODEL <br /> BUILDING USE: ❑SFR ❑TOWNHOUSE ❑ DUPLEX ❑ADU ❑ MULTI-FAMILY-#OF UNITS: FICOMMERCIAL <br /> 73). EL ICAL APPLICATION IN 'FORMATION fe'DESCRIPTION OF;WORK <br /> CONTRACT <br /> ECTTR <br /> RACT PRICE OF WORK:$ ; DO U ASSOCIATED BUILDING PERMIT#(if applicable): GY - C �] <br /> DESCRIBE SCOPE OF WORK: Ae?t v= e ' // / e , <br /> v is /371lzj i'A l .;2. itcl'17 .. c. ' (:i J) /Ye, ,c- /, <br /> Po <br /> THIS INSTALLATION INCLUDES THE FOLLOWING SCOPE: (SELECT� ALL THAT APPLY) <br /> LINE VOLTAGE WORK? ElN'NO E 4ES-Select Scope: L� Se L rvice rl Feeder Circuits-#: ❑Complete Re-wire <br /> LOW VOLTAGE WORK? 0 NO ❑YES-#of Devices:es <br /> SELECT SCOPE(REQUIRED): ❑ Data El Intercom Lam"I hermostat ❑Audio ❑ Secure Access ❑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 /> ❑Other(List All): <br /> CODE,COMPLIANCE <br /> IS THIS PERMIT EDUCATION,INSTITUTIONAL,HEALTH AND/OR PERSONAL CARE FACILITIES: NO n 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 YOU AN OWNER PERFORMING WORK AS THE CONTRACTOR WITHOUT ELECTRICAL LICENSURE:NNO EYES-See Below&Pg.3 <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: Du i:.-. c e :'� ,t, '=/ TENANT BUSINESS NAME(If Commercial): <br /> OWNER MAILING ADDRESS: STREET yLIL—re <br /> &z.i � „ <br /> CITY /i-'era J `STATE �1 ZIP elf <br /> OWNER PHONE %a w T`/ .S"" OWNER EMAIL cis;c ': -.G! ` . ,. �t J �.,. C C)r+-t... <br /> CONTRACTOR NAME: ,f-3 c.„/ L /_% r L <br /> CONTRACTOR ADDRESS: STREET f' 0 13 <br /> CITY ;./ j �� �CI✓7 STATE 1.1)A ZIP ; -- <br /> CONTRACTOR PHONE:,3e ,/) 7(; 7 `L►�1'..I CONTRACTOR EMAIL:( /j L'C k 11 /)y eN <br /> CONTRACTOR LIC.#(REQUIRED): CITY OF EVERETT BUSINESS LIC #(REQUIRED): <br /> PRIMARY CONTACT: ❑OWNER CONTRACTOR ❑OTHER(Please Specify) <br /> CONTACT NAME: <br /> // CONTACT PHONE: i/id.t-- ('7 _:�` ' <br /> L�/i(. C ., /7G' CONTACT EMAIL: )." c •'c c <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#: r,,� <br /> I 'v `�l c� E D l0 <br /> vfinerlAuthorized Agent Signature Date (Revised 1/11/2019) ( Page 7�Application\ <br />