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1110 i <br /> LTA ELECTRICAL PERMIT APPLICATION <br /> EVERETT 32 CITY OF EVERETT PERMIT SERVICES <br /> 00 CEDAR STREET,EVERETT,WA 98201 <br /> WASHINGTON (P)425-257-8810 I FAX425-257-8857 I(E)everetteps@everettwa.gov I www.everettwa.gov/permits <br /> PROJECT SITE INFORMATION <br /> PROJECT ADDRESS: (UC'3 r:.i'JJFp45/nV fZtki't SvrTE /S ,CVER•1 far BUILDING AREA: Ycr'O(i sq ft <br /> PROJECT TYPE: ❑ NEW CONSTRUCTION ❑ADDITION El TENANT IMPROVMENT ❑ REMODEL <br /> BUILDING USE: ❑ SFR ❑ TOWNHOUSE ❑ DUPLEX ❑ADU ❑ MULTI-FAMILY-#OF UNITS: 'COMMERCIAL <br /> ELECTRICAL APPLICATION INFORMATI,ONr& DESCRIPTION.OF,WORK h <br /> CONTRACT PRICE OF WORK:$ ���/Ot:U ASSOCIATED BUILDING PERMIT#(if applicable): .D\A,D�+V3 1 <br /> DESCRIBE SCOPE OF WORK: CO61 1111,M I C 11-16 1S Sy_crE '►S (O°rT(� ) , 1 RLLtSS P CCLSS PCJAITS • <br /> THIS INSTALLATION INCLUDES THE FOLLOWING SCOPE: (SELECT ALL THAT APPLY) <br /> LINE VOLTAGE WORK? NO �� €5-Selec)Scope: ❑ Service ❑ Feeder ©'CircOtts.-/#' ❑ Complete Re-wire <br /> LOW VOLTAGE WORK? El NO ®YES-#of Devices: I (t- <br /> SELECT SCOPE(REQUIRED): LJ.Data ❑ Intercom ❑Thermostat ❑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: Q NO ❑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:.❑NO EIYES-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: -A TENANT BUSINESS NAME(If Commercial): <br /> OWNER MAILING ADDRESS: STREET G,C1 P-i I 6- P-O.111 CL <br /> 5L i rL <br /> CITY EUe { 1-r1 STATE ZIP 9V / <br /> OWNER PHONE: OWNER EMAIL: <br /> CONTRACTOR NAME: E2 OPPC-S <br /> CONTRACTOR ADDRESS: t_ <br /> STREET <br /> Q � tl� f)' <br /> O 12 UL A/E , $ E V?T ?I IG�_r <br /> CITY Beu VL. <br /> -E _ STATE ,V�/4 ZIP /15°C5S--- <br /> CONTRACTOR PHONE: q2-5--466-4/o//4e CONTRACTOR EMAIL: 61 LEI'I h 1 e2.4)P «W1 <br /> CONTRACTOR LIC.#(REQUIRED): EZG P d C L uJ/ 1 /C.( CITY OF EVERETT BUSINESS LIC.#(REQUIRED): �j�L'c* <br /> PRIMARY CONTACT: DOWNER F1CONTRACTO �� ��� � _ _ � <br /> R ❑OTHER(Please Specify) <br /> CONTACT NAME: CONTACT PHONE: qLSC - " yylc� <br /> Al hL/>' CONTACT EMAIL: 11-C_O = 1 SS( (2e pi)CC cG07 <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#: <br /> V2V261, E \ U(C' \(6(0 <br /> Owner/Authorized Agent Signature Date (Revised 1/11/2019) Page 1-Application <br />