Laserfiche WebLink
0 10 <br />ELECTRICAL PERMIT APPLICATION <br />EVERETT CITY OF EVERETT PERMIT SERVICES <br />3200 CEDAR STREET, EVERETT.. WA 98201 <br />WASHINGTON (P) 425-257-8610 i FAX 425-257-8857 ! (E) everetteps@everettwa gov I www.everettwa.gov/permits <br />IU&INFAURMAT!ON <br />PROJECT ADDRESS: d0Q <br />BUILDING AREA: sq ft <br />PROJECT TYPE: ❑ NEW CONSTRUCTION ❑ ADDITION ❑ TENANT IMPROVMENT ❑ REMODEL <br />BUILDING USE: LJ SFR ❑ TOWNHOUSE El DUPLEX ❑ ADU ❑ MULTI -FAMILY - # OF UNITS: ❑ COMMERCIAL <br />ATION,,,I ,. F.... _ ..... DESCRIP71ON OF WORK <br />. _.. . <br />CONTRACT PRICE OF WORK: $ 21, oo ASSOCIATED BUILDING PERMIT # (if applicable): <br />DESCRIBE SCOPE OF WORK: <br />THIS INSTALLATION INCLUDES THE FOLLOWING SCOPE: (SELECT ALL THAT APPLY) <br />LINE VOLTAGE WORK? ❑ NO YES - Select Scope. ❑ Service ❑ Feeder ❑ Circuits-#: Complete Re -wire <br />LOW VOLTAGE WORK? NO YES- # of Devices: <br />SELECT SCOPE (REQUIRED) 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 />.-,., _ ...._ , . <br />'CODE,_COMPLIANCE: <br />IS THIS PERMIT EDUCATION, INSTITUTIONAL, HEALTH AND/OR PERSONAL CARE FACILITIES: NNO U 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 DYES -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 />u 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•, ,.. ... m <br />OWNER NAME: TENANT BUSINESS NAME (If Commercial): <br />OWNER MAILING ADDRESS: STREET <br />rtTy STATE ZIP <br />OWNER PHONE: <br />OWNER EMAIL: <br />CONTRACTOR NAME: G <br />CONTRACTOR ADDRESS: STrtcer <br />C- STnTe w ZIP <br />CONTRACTOR PHONE: ;' ', ` " <br />CONTRACTOR EMAIL: LILL d m <br />CONTRACTOR LIC. #(REQUIRED): <br />CITY OF EVERETT BUSINESS LIC. #REQUIRED}:Li <br />PRIMARY CONTACT: DOWNER KGONTRACTOR ❑OTHER (Please Specify) <br />CONTACT NAME: <br />CONTACT PHONE: <br />Lk i <br />CONTACT EMAIL: UGCV C6 �rvm <br />r u;m==mcry i t nemay cerury inar i nave reao and examined rnis appmation and Know the same to be true ana Correct Alt provisions or taws 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 />focal law regulating construction or the performance of construction That I am authorized by the owner of this properly to perform the work for which application is made and I <br />comply with the State Contractors' w 18.27 RCW and 296.200 WAC City of Everett Official Use Only <br />PERMIT #: <br />E <br />i 222� <br />Owner/Author a ent Signature [7 (Revised 1/11/201) Page 1-Application <br />