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<br /> ELECTRICAL PERMIT APPLICATION
<br /> CITY OF EVERETT PERMIT SERVICES
<br /> 3200 CEDAR STREET,EVERETT,WA 982271
<br /> (M42 2st-&1o;I FFAXe2,274 ST I(C)everat • everoftwaem www,svareltwagodpermits
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<br /> PROJECT ADDRESS: a elDs, /lire titu:i" CTT WA griStict} BUILDING AREA:_ ft
<br /> PROJECT TYPE: El NEW CONSTRUCTION CI ADDITION TENANT IMPROVMENT Q REMODEL
<br /> BUILDING USE: SFR CI TOWNHOUSE CI DUPLEX ©ADU CI MULTI-FAMILY-4 OF UNITS ct mmEacIAt.
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<br /> CONTRACT PRICE OF WORK:$ Z"700 4-S—; ASSOCIATED BUILDING PERMIT#(if applicable):
<br /> DESCRIBE SCOPE OF WORK: 11 f)CT c..'1t> Elie:
<br /> THIS INSTALLATION INCLUDES THE FOLLOWING SCOPE:. SELECT ALL THAT APPLY
<br /> LINE VOLTAGE WORK? 19 NO CI YES»Select Sco :Cl Service 0 Feeder 0 Circuits-It, 0 Cm to Re-wire
<br /> LOW VOLTAGE WORK? Q NO YES-S of Devices Li
<br /> SELECT SCOPE(REQUIRED): Cl Data Q Intercom 0 Thermostat Q Audio CI Secure Access 0 Security System
<br /> Eire Alarm»Installations under this permit only in ls.Tde electrical wiring rough-in of the system.An additional
<br /> Fire Alarm Permit is required for review of device location and inatellatlon approval.
<br /> Q Other(List All) _
<br /> , $$ n5 �. .:. 4.h 1.i
<br /> 1S THIS PERMIT EDUCATION,INSTITUTIONAL,HEALTH ANDfOR PERSONAL CARE FACILITIES: NO U YES--See Below&Pg.2
<br /> By cheoklrtg this box.I am stating that I have read and understand sit of WAC zoo-406.900,selected the ispecific reason on page 2
<br /> Liei of this stylisation(see next page),AND Plan Review is NOT required because I tit all of the following sub sections that do not
<br /> See Peas 2 require Plan Review.
<br /> ARE YOU AN O IER PERFORMING WORK AS Tf4E CONTRACTOR WITHOUT ELECTRICAL LICENSURE: NO YES-See Below&Pg,3
<br /> in Pursuant to ROW 19.28.281,property owners and leaseholders cannot perform electrical work on buildings for rent,sale,or lease
<br /> without the proper eitictricei licensing and certification,or exemption.By checking this box,I am stating that I have completed and
<br /> aria pttuti g signed the AFFIDAVIT en page 3 of this application to receive en exemption from this licensing/Certification requirement.
<br /> Of .
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<br /> OWNER NAME:Bt't 7457'irlts„7 -CAStA A IA)ti) TENANT BUSINESS NAME If Commercial:
<br /> OWNER MAILING ADDRESS: s'rwssr ,,gsoa t I(r8,v5,
<br /> atry veat:TT area WA ZIP 14,' 8d
<br /> pHONE: . f) tit OWNER EMAIL
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<br /> CONTRACTOR ADDRESS, sweat Ap 94,711k. I 1
<br /> _ cm N i„.IN)4-1s.) . ,STATE VvIA ZIP '2-7:3
<br /> CONTRACTOR PHONE:1, 'S 244 144 CONTRACTOR EMAIL: CA4 S t.JHFI ft. ,,.LvYrs
<br /> ;CONTRACTOR(J , REQUIRED: Ira F I R.1i Z. CITY OF EVERETT etliONESS LIC, REQUIRED:C?5' 7
<br /> PRIMARY CONTACT: I OWNER CONTRACTOR 0 OTHER(Please Specify)
<br /> CONTACT NAME: CONTACT PHONE: aft t J 115.'
<br /> 9.44755` CONTACT EMAIL: R x?FI 1.)(LIe..+Wir`w -
<br /> ACREEit I4;4 y cacti,that haw.reed and awTminad t)oe kmsw Me sametabs trueatiti=Ma pm4ebes otiose wrilaarea gtWerningttrt
<br /> type duo*vie be competed whether specNaci frees or not The("waling of a patina dons.not prostrate to giwt authority to violate or mice/the pros/Micas of say ether stets or
<br /> local ISM,regueitiv toostrtofkett or the pettormance or conetrzxftoa That t eevto authort ed by the mow of the primerfy to petkirm the work Tor which fatten s mae*and I
<br /> comply with the State C nfresiora Law 1E 27 ROW end 204,40 WAC - City of Everett Offciii Use tnly
<br /> pERmer#:
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<br /> Owaer`JAu rined Agent Signatory date Revised 1/11/i01S P� } dptleaNan
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