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ELECTRICAL PERMIT APPLICATION <br />CITY OF EVERETT PERMIT SERVICES <br />EVERETT 3200 CEDAR STREET, EVERETT. WA 98201 <br />WA$WNGTON (P) 425-257-8810 1 FAX 425-257-8857 1 (E) everettaps@everettwa gov I "ww everettwa govipermits <br />CTW , JNFORMATION <br />PROJECT ADDRESS: 4630 31 st Ave SE IBUILDING AREA: sq ft <br />PROJECT TYPE: Z NEW CONSTRUCTION D ADDITION D TENANT IMPROVMENT 0 REMODEL <br />BUILDING USE: EV-,'SFR [I TOWNHOUSE 71 DUPLEX [] ADLI El MULTI -FAMILY - # OF UNITS, COMMERCIAL <br />PRICE OF WORK: $ 250 <br />BUILDING PERMIT # (if applicable): <br />THIS INSTALLATION INCLUDES THE FOLLOWING SCOPE: (SELECT ALL THAT APPLY) <br />LINE VOLTAGE WORK? [21 NO Fj YES - Select Scope: 1:1 Service [I Feeder [] Circuits-#: Complete Re -wire <br />LOW VOLTAGE WORK? 1Z NO F7 YES- # of Devices, <br />SELECT SCOPE /REQUIRED). ❑ Data F-1 Intercom Ej Thermostat Ej 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 />F1 Other (List All) - <br />IS THIS PERMIT EDUCATION, INSTITUTIONAL, HEALTH AND/OR PERSONAL CARE FACILITIES. 1,/INO I IYES -- 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: 7V.,NO [7YES -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 licensing1certification requirement. <br />JOWNER NAME: Polygon Homes TENANT BUSINESS NAME (If Commercial): <br />1OWNER MAILING ADDRESS: STREET 11624 SE 5th St Ste 100 <br />Bellevue STATF. WA 98005 <br />1OWNER EMAIL: <br />NAME: Garner Electric WA LLG <br />ADDRESS: STRE,__402 Valley Ave NW Ste106 <br />I '_'Ty Puyallup S'_A7,", WA 1, 98371 1 <br />CONTRACTOR PHONE: 253-872-6051 1CONTRACTOR EMAIL: agentele@gweusa.com <br />CONTRACTOR LtC. #(REQUIRED): GARNEEA'864KB CITYOFEVERETT BUSINESS LIC. #(REQUIRED): 052909 <br />PRIMARY CONTACT. EOWNER 7CONTRACTOR COTHFIR (Please Specify)—__ <br />ICONTACT NAME: ICONTACT PHONE: 253-278-7064 <br />Paul Van'LU I ICONTACT EMAIL: pvantoi@gweusa.com <br />same <br />type of work will be completed whether spec lied herein or not The granting or permit does not presume to give authonV to waiate at conc,4 the prowsions of any other state or <br />lc law regulating construction or the performance of construction. That I am authonzed by the Owner of this properly to perform the work for which applicat;on es made and I <br />comply with the State Contractors Law, 14,27 RCW and 296.200 WAC City of Everitt Official Use Only <br />< <br />PERMIT <br />912412019 E <br />-5in- .Re wsed 1/11,12019) Page I -Application <br />0 erfAuthorizetl Agent Si Date ( <br />