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0 0 <br /> ELECTRICAL RICAL PERIIIiIT ic-VTL CATOC)N <br /> CITY OF EVERETT PERMIT SERVICES <br /> F_IfF T 3200 CEDAR STREET,EVERETT,WA 98201 <br /> (P)425-257-8810 I FAX 425-257-8857 I(E)everetteps@everettwa.gov I www.evereltwagov/permits <br /> —_. PROJECT SATE INFORMATION _ <br /> � `\' i <br /> PROJECT ADDRESS: `�`lj \ l `! BUILDING AREA: sq ft <br /> PROJECT TYPE: 0 NEW CONSTRUCTION O'ADDITION 0 TENANT IMPROVMENT 0 REMODEL <br /> BUILDING USE: ®SFR 0 TOWNHOUSE ®DUPLEX 0 ADU 0 MULTI-FAMILY-#OF UNITS: 0 COMMERCIAL <br /> ELECTRICAL APPLICATION:INFORMATION.& DESCRIPTION OF WORK, <br /> CONTRACT PRICE OF WORK:$ l" 00— ASSOCIATED BUILDING PERMIT#(if applicable): r <br /> DESCRIBE SCOPE OF WORK: 1=iV.c) WC `('(0 `SUS/7)4'A--01 (,l(r'\( lh/N({ 0 Cl de,V\L 3. <br /> THIS INSTALLATION INCLUDES THE FOLLOWING SCOPE: (SELECT ALL THAT APPLY) <br /> LINE VOLTAGE WORK? 0 NO 0 YES-Select Scope: 0 Service 0 Feeder 0 Circuits-#: 0 Complete Re-wire <br /> LOW VOLTAGE WORK? 0 NO 0 YES-#of Devices: I t <br /> SELECT SCOPE(REQUIRED): 0 Data 0 Intercom 0 Thermostat 0 Audio 0 Secure Access 0 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 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 /> 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: 1111.410 ®YES-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 /> i <br /> OWNER NAME: 1 TENANT BUSINESS NAME(If Commercial):ilr'lle C\ili.A` l►\t.j fA It1(N(' <br /> OWNER MAILING ADDRESS: STREETy�\O \ (,.1)`�' ' °�t. _ <br /> CITY \ 4 P'(D*'�— STATE 4 A ZIP CtI j�.0 <br /> OWNER PHONE: OWNER EMAIL: <br /> CONTRACTOR NAME:,,^,, ,,A, V( ),' jk.k --fAgt 7° -�' �A-IC' '�(\ <br /> "�p <br /> CONTRACTOR ADDRESS: STREET//� 1 �� A t_ ,{/�{ �] <br /> CITY /Kl I,y,' STATE \f V/\ ZIP (—\�\� <br /> CONTRACTORPHONEI-'')' 11�W-2 k+LQ ONTRACTOREMAIL:h1 )1Cfp1B'v\Ly'V (1k.\r,_;"trt1l41ci Ai �Kl <br /> CONTRACTOR LIC.#(REQUIRED):(—li WN-1-7 I ...lam CITY OF EVERETT BUSINESS LIC.#(REQUIRED): c � 3 <br /> PRIMARY CONTACT: El OWNER I?CONTRACTOR ❑OTHER(Please Specify) <br /> CONTACT NAME: CONTACT PHONE: (AL10) ( ) ( 1.-‘-,(v <br /> T. ),l'r - \( �t C a �, CONTACT EMAIL: t r'\\(`,\ ( ,_\1 i(c.A,,'`i \vi ( 'i, V At.i t^r,,e.--, <br /> ,. �r � VtC�� 1v C_ �1 W�{L te1 ) <br /> AGREEMENT::I hereby certify that I have read&ifi examined this application and know the same fb be due and correct. All provisions of laws and ordinarldes 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#: <br /> C\:-.--ikt c l ACrtt \ yr. I OA(9,6 E21)09b-1(0 <br /> Owner/Authorized'Agent Signature Date (Revised 1/11/2019) Page 1-Applicatiot" <br />