10306 27TH DR SE 2021-12-15 - Laserfiche WebLink

ELECTRICAL PERMIT APPLICATION EVERETT 32CITY OF EVERETT PERMIT SERVICES 00 CEDAR STREET, EVERETT, WA 98201 WASH INrTnN (P) 425-257-8810 1 FAX 425-257-8857 1 (E) everetteps@everettwa.gov I www.everettwa.gov/permits. PROJECT SITE INFORMATION 1 PROJECT ADDRESS: `©� G) Z rI V �Z 5 BUILDING AREA: sq ft PROJECT TYPE: ❑ NEW CONSTRUCTION ❑ ADDITION ❑ TENANT IMPROVMENT ❑ REMODEL BUILDING USE: ❑ SFR ❑ TOWNHOUSE ❑ DUPLEX ❑ ADU ❑ MULTI -FAMILY - # OF UNITS: ❑ COMMERCIAL ELECTRICAL APPLICATION",INFORMATION'& `DESCRMT[.ON OF VWORK ... : ` CONTRACT PRICE OF WORK: $ 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 COMPLIAhICE .. .. IS THIS PERMIT EDUCATION, INSTITUTIONAL, HEALTH AND/OR PERSONAL CARE FACILITIES: XNO Lj YES -- See Below & Pg. 2 ❑ By checking this box, I am stating that I have read and understand all of WAC 29f; 46R 90d, s ected 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 VEES -See Below & Pg. 3 ❑ Pursuant to RCW 19.28.261, property owners and leaseholders cannot perform electrical work on buildingsi6rvnt, sale, or lease 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. Ct# t`AOT INI=Oi liN tTlON OWNER NAME: 1. 4osxx . ?r64 APv'3 TENANT BUSINESS NAME (If Commercial): OWNER MAILING ADDRESS: STREET 22- o .Z C\ \,C tr CITY CAY S (J STATE `-� — � � ZIP OWNER PHONE: 2 �� `� �� `Q2 1 OWNER EMAIL: �� CG ko Axc re �k e V-s" C c "i'l CONTRACTOR NAME: CONTRACTOR ADDRESS: STREET Aj CITY STATE ZIP CONTRACTOR PHONE, CONTRA MAIL: CONTRACTOR LIC. #(REQUI ED): OF EVERETT. BUSINESS LIC. #(REQUIR ): _. .....,_.._ ,..... ....... .._�..... _.. _. _ _.._..-..,_.. ..... ... PRIMARY CONTACT: &OWNER ❑CONTRACTOR ❑OTHER (Please Specify) CONTACT NAME: e 1 CONTACT PHONE: CONTACT EMAIL: AGKLLMLN l: i nersoy cerwy mar i nave reap ana examines rms appucauon ano Know mu same to ue true rnru cUfru . nrr µrvvrmvr,a ur ,awo of, v,uu,a... type of work will be completed whether specked 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 perfoCRa nte f construction. That I am authorized by the owner of this property to perform the work for which application is made and/ comply 1 y�'thj�e State Contractors Law 18.2CW/�d 296.200 WAC. City of Everett Official Use Only %( /% IPERMIT #: � A� � � V�\tT -fz-r/ I E `(�cc, _ C)45 Owner/ uthor d _ en ig ature Date (Revised 111112019) Page 1-Application