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EMU • 0 ELEC T fflCAL PERMIT APPLICATIOM CITY OF EVERETT PERMIT SERVICES EVERETT 3200 CEDAR STREET, EVERETT, WA 98201 WASHINGTON (P)425-257-8810 1 FAX425-257-8857 I(E)everetteps@everettwa.govI wwvw.everettwa.gov/permits PROJECT SITE INFORMATION PROJECT ADDRESS: ; jCt F�� }�� r� C� 4ZU � BUILDING AREA: sq ft PROJECT TYPE: ❑✓NEW CONSTRUCTION 0 ADDITION ❑ TENANT IMPROVMENT ❑ REMODEL BUILDING USE: [ SFR ❑ TOWNHOUSE ® DUPLEX ❑ ADU ❑ MULTI -FAMILY - # OF UNITS: ❑ COMMERCIAL ELECTRICALAPPLICATIONINFORMATION $r DESCRIPTION OF WORK CONTRACT PRICE OF WORK: $ 4 �/ , ®� ASSOCIATED BUILDING PERMIT # (if applicable): DESCRIBE SCOPE OF WORK: THIS INSTALLATION INCLUDES THE FOLLOWING SCOPE: (SELECT ALL THAT APPLY) LINE VOLTAGE WORK? ❑ NO ❑ YES - Select Scope: ❑ Service ❑ Feeder ❑ Circuits-#: ❑ Complete Re -wire LOW VOLTAGE WORK? ❑ NO ❑ YES- # of Devices: SELECT SCOPE (REQUIRED): ❑ Data ❑ Intercom ❑ Thermostat ❑ Audio ❑ Secure Access ❑ Security System ❑ Fire Alarm - Installations under this permit only include electrical wiring rough -in of the system. An additional Fire Alarm Permit is required for review of device location and installation approval. ❑ Other (List All): CODE COMPLIANCE IS THIS PERMIT EDUCATION, INSTITUTIONAL, HEALTH AND/OR PERSONAL CARE FACILITIES: NO YES -- See Below & Pg. 2 ❑By checking this box, I am stating that I have read and understand all of WAC 296-4613-900, selected the specific reason on page 2 of this application (see next page), AND Plan Review is NOT required because I meet all of the following sub sections that do not See Page 2 require Plan Review. ARE YOU AN OWNER PERFORMING WORK AS THE CONTRACTOR WITHOUT ELECTRICAL LICENSURE: ❑NO r YES -See Below & Pg. 3 j Pursuant to RCW 19.28.2131, property owners and leaseholders cannot perform electrical work on buildings for rent, sale, or lease u without the proper electrical licensing and certification, or exemption. By checking this box, I am stating that I have completed and See Page 3 signed the AFFIDAVIT on page 3 of this application to receive an exemption from this licensing/certification requirement. CONTACT INFORMATION OWNER NAME: k TENANT BUSINESS NAME (If Commercial): OWNER MAILING ADDRESS: STREET ��) �' < �/ CITY STATE G'Vzip t- C' 3 OWNER PHONE: OWNER EMAIL: )CrJ117A)fsci J r -1I C;Wtil Cf� i CONTRACTOR NAME: I �i; 1wa<—' (t IC CONTRACTOR ADDRESS: STREET CITY STATE ZIP CONTRACTOR PHONE: 20 qqq5 2- Zc CONTRACTOR EMAIL: 'j JI" Go" CONTRACTOR LIC. #(REQUIRED): / r CITY OF EVERETT BUSINESS LIC. #(REQUIRED): .a._ ...........K. . . .......... .v... - _. ......... _., , . _ ..... PRIMARY CONTACT: ©OWNER v CONTRACTOR ❑OTHER (Please Specify) CONTACT NAME: H CONTACT PHONE: z5 - Zu L- //,ter✓ CONTACT EMAIL: -,,,ed %7gly"�// )I Iy1�i,�,�•+^A AGREEMENT: I hereby certity Matt have read and examined this appucanon and know me same to oe true eno coned. n❑ pruvWUIIs 1a a11U VI ,y . ,— 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 local law regulating construction or the performance of construction. That 1 am authorized by the owner of this property to perform the work for which application is made and I comply with the State Contractors Law 18.27 RCW and 296.200 WAC. City of Everett Official Use Only PERMIT #: 13 Owner/Authorized Agent Signature Date (Revised 111112019) Page 1-/Application �1,