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02/25/2020 09:05 3604740126 DONNELSON ELECTRIC INC #4149 P. 001 /001
<br /> •ECTRICAL PERMIT APP :ATION
<br /> EVERETT 32 CITY OF EVER=PERMIT SERVICES
<br /> 00 CEDAR STREET,EVERE I t,WA 98201
<br /> WASii1NGTON (P)425-257-8810 I FAX 425.-257-8857 i(E)everettep www
<br /> .everettwagov/permirs
<br /> I ww,everettwa.gov/permits
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<br /> PROJECT�ADD�RE�S�s���,•,1aOZ� � jr
<br /> ���,�. 6eev'Pre7r, ," �,,,,.,; . BUIL�NG�A�R���1�,a���;�a�V�`�; v<°���,i���1� ,,� ,i���� ���,��
<br /> 9
<br /> PROJECT TYPE: 12 NEW CONSTRUCTION El ADDITION El TENANT IMPROVMENT ❑ REMODE O
<br /> BUILDING USE: 14 SFR ❑ TOWNHOUSE ❑ DUPLEX Cl ADU ❑ MULTI-FAMILY-#OF UNI OMMERCIAL
<br /> 10�r :"40110 �� , a,• � � 101110.777.77.
<br /> I ��,�
<br /> CONTRACT PRICE OF WORKAp� (ASSOCIATED PERMIT#(If applicable):DESCRIBE SCOPE OF WORK: /,/Q k/ he
<br /> THIS INSTALLATION INCLUDES THE FOLLOWING SCOPE: (SELECT ALL THAT APPLY)
<br /> LINE VOLTAGE WORK? ❑ NO g YES-Select Scope: ® Service ❑ Feeder ❑ Circuits-#:/V/ ❑ Complete Re-wire
<br /> LOW VOLTAGE WORK? ❑ NO ❑YES-#of Devices:
<br /> SELECT SCOPE(REQUIRED): ❑ Data ❑ Intercom El Thermostat ❑Audio ❑Secure Access El 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 /> u1` `pg�� `ryp' ❑ Other(List AJI):
<br /> ,` lt�`'\.Ri'.�11'N.1\ 'i,. ���I ` r 1rv�V1C �t �1 1 ` 11,1� 111 \u�� \`1 �,1�t111'`w',
<br /> '1 1 A �� 51 , J1W � th � 1 1,`�9n1���i�..��.,`.lx�`:�,n� l .
<br /> IS THIS PERMIT EDUCATION, INSTITUTIONAL,HEALTH AND/OR PERSONAL CARE FACILITIES: ii-NCB • 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: 0.❑'INO EYES-See Below&Pg.3
<br /> l l 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 /> gee Page g signed the��,A,11,p�FFEDAVIT on page 3 of this application to receive an exemption from this licensing/certification requirement_
<br /> .\\ 1,�,\ \"\.`, \'l` ��111111�11,t1, ds """� w' de a" i 1` 1' aC 1 �1J 1hl,i i
<br /> BaccLr,` /7'oe.%es Inc TENANTBUSINES ���� ,.,,��.\�a4,1 1 ,......,;; :
<br /> OWNER NAME: NAME(If Commercial):
<br /> OWNER/ `- / MAILING+A/DDRESS: STREET ,3/( /O3r ej 4t/e /Ve r J,Q GQ-oiiC€ T Y�j GITY ® STATE 1 //• ZIP —(I/261
<br /> OWNER PHONE: /Z3 -2 9-O'QQ OWNER EMAIL: GGk/'a�1011r>Ie &p7,57K
<br /> - CONTRACTOR NAME: Dan✓tef$Oc efp��'r,-c
<br /> CONTRACTOR ADDRESS: STREET 13Gt ,/ice • Q// ViC /1-1/t !!� j� q Q T
<br /> !1R'ri°J 0^ cm' 'STATE I""�4 ZIP /vZL7
<br /> CONTRACTOR PHONE:L✓45---23,--L174/ CONTRACTOR EMAIL:Do4//'/Son, e%G f ,C Q Frory-fi Pi; n.
<br /> CONTRACTOR LIC.#(REQUIRED):0p/InG�i 04141 PZ CITY OF EVERETT BUSINESS LIC.#(REQUI RED):03/'Z3 7
<br /> PRIMARY CONTACT: ❑OWNER ilf( CONTRACTOR EOTHER(Please Specify)
<br /> CONTACT NAME: CONTACT PHONE: �7 z3g_ 'i76 I
<br /> S097T FCn.STermett CONTACT EMAIL: Donne/Sal• leiecl-cvc Cork
<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 constru ion 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 t tors Law 18. W and 296.2QQ WAC. City of Everett Official Use Only
<br /> PERMIT#:
<br /> • ._ ?C7 E Zap? —Zc
<br /> owner/Authorized Agent Signature Date —
<br /> (Revised 1/11/2019) Page 1-Application
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