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0 • <br />ELECTRICAL P RNT APPLICATIOI <br />CITY OF EVERETT PERMIT SERVICES <br />3200 CEDAR STREET, EVERETT, WA 98201 <br />roe OF7_P810 1 FAx 425-257-9857 1 (E) eve rettepS(dbeverettwa.gov 1 www.everettwa.gov/permits <br />PROJECT SITE INFORMATION -_Fs <br />PROJECT ADDRESS: (-{(,? 1 "I S-t- Evt +' NA 66 I I BUILDING AREA: =1^ sq ft <br />PROJECT TYPE: NEW CONSTRUCTION ❑ ADDITION ❑ TENANT IMPROVMENT ❑ REMODEL <br />BUILDING USE: ❑ SFR ❑ TOWNHOUSE ❑ DUPLEX ❑ ADU ❑ MULTI -FAMILY - # OF UNITS: RCOMMERCIAL <br />ELECTRICAL APPLICATION INFORMATION a DESCRIPTION OF WOR <br />CONTRACT PRICE OF WORK: $ ,_ zoo. CX� ASSOCIATED BUILDING PERMIT # (if applicable): <br />1-1 DESCRIBE SCOPE OF WORK: ,_ G t� �. ;- art; 11<:.1t•-, i <br />THIS INSTALLATION INCLUDES THE FOLLOWING SCOPE: (SELECT ALL THAT APPLY) <br />LINE VOLTAGE WORK? ❑ NO YES - Select Scope: ❑ Service Feeder Circuits-#: V-, ❑ Complete Re -wire <br />LOW VOLTAGE WORK? �10 Ill YES- # of Devices: ,�yd <br />Data ❑ Intercom ❑ Thermostat ❑Audio secure Access [3 Security System <br />SELECT SCOPE (REQUIRED): <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 AYES -- See Below & Pg. 2 <br />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 <br />do <br />of this application (see next page), AND Plan Review is NOT required because I meet all of the following sub sections that not <br />See Page 2 require Plan Review. <br />WORK AS THE CONTRACTOR WITHOUT ELECTRICAL LICENSURE: ❑NO OYES See Below & Pg. 3 <br />ARE YOU AN OWNER PERFORMING <br />Pursuant to RCW 19.28.261, property owners and leaseholders cannot perform electrical work on buildings for rent, sale, or lease <br />have and <br />without the proper electrical licensing and certification, or exemption. By checking this box, 1 am stating that I completed <br />the AFFIDAVIT on page 3 of this application to receive an exemption from this licensing/certification requirement. <br />See Page 3 signed <br />CONTACT INFORMATION <br />OWNER NAME: �':'s • ,x�Cwa IBC :--yt�;� �� TENANT BUSINESS NAME If Commercial): <br />v' Lz •���U� 7v� <br />OWNER MAILING ADDRESS: STREET �j <br />gel J <br />STATE `� I ZIP <br />CITY 1`i••:rl �"i• :: <br />OWNER EMAIL: <br />OWNER PHONE: <br />CONTRACTOR NAME: ' r (-4-k <br />CONTRACTOR ADDRESS: STREET /f J�j <br />ZIP `l <br />CITY -�''C.- STATE 11.%,T <br />CONTRACTOR PHONE: CONTRACTOR EMAIL: <br />LIC. #(REQUIRED): Lio <br />CONTRACTOR LIC. #(REQUIRED): V f-C-lk ICITY OF EVERETT BUSINESS „l'4 <br />PRIMARY CONTACT: El OWNER ❑CONTRACTOR QOTHER (Please Specify) 'r . <br />CONTACT NAME: <br />CONTACT PHONE: j (� _ .IV< <br />CONTACT EMAIL' <br />� a' �tti.��I,.;:..� � <br />V <br />_ ___,:_ .:,.� ..., !,.IL: rr,o came to be trna and rnrrect. All orovisions of laws and ordinances governing this <br />AGREEMENT.' 1 hereby certrty mat / have read and exanwrau rills oNN„ a ,1„ u••w •,- <br />