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<br /> 1P7-/-7:4 ELECTRICAL PERMIT APPLICATION
<br /> CITY OF EVERETT PERMIT SERVICES
<br /> 3200 CEDAR STREET,EVERETT,WA 98201
<br /> (P)425-257-8810 I FAX 425-257-8857 J(E)everetteps@everettwa.gov I www.everettwa.gov/permits
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<br /> PROJECT ADDRESS: 5819 12TH AVE W BUILDING AREA: sq ft
<br /> PROJECT TYPE: ❑NEW CONSTRUCTION ✓❑ADDITION ❑TENANT IMPROVMENT ❑REMODEL
<br /> BUILDING USE: D SFR ❑TOWNHOUSE El DUPLEX ❑ADU ❑MULTI-FAMILY-#OF UNITS: ❑COMMERCIAL
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<br /> CONTRACT PRICE OF WORK:$ 400.00 ASSOCIATED BUILDING PERMIT#(if applicable):
<br /> DESCRIBE SCOPE OF WORK:
<br /> STAT WIRE
<br /> THIS INSTALLATION INCLUDES THE FOLLOWING SCOPE: (SELECT ALL THAT APPLY)
<br /> LtNE1lOLT_A;C9 WQRK ❑NO:' DYES: Selectscope ❑Service.-- __.e.....,_ ....... ❑;Feeder ❑Circuits . ❑Com.plete.Re-wire
<br /> LOW VQ:LTAGE WORK? ❑NO: ❑✓ YES-#ofDevices
<br /> SELECT SCOPE•;(REQUIRED):-❑Data ❑1_nt rcom 0 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):
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<br /> IS THIS PERMIT EDUCATION, INSTITUTIONAL,HEALTH AND/OR PERSONAL CARE FACILITIES: ✓❑NO El YES—See Below&Pg.2
<br /> I 1 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 /> 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.
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<br /> OW. NERNAME:, MICHAEL KIMBERLIN TENANT BUSINESS NAME(If Commercial):
<br /> OWNERMAILING ADDRESS:: STREET 5819 12TH AVE W
<br /> Crrr EVERETT STATE WA ZIP 98203
<br /> OWNER PHONE:4253080420 OWNER;EMAIL;MIKE149149@GMAIL.COM
<br /> CONTRACTOR NAME: gs heating
<br /> CONTRACTOR ADDRESS: STREET3409 everett ave
<br /> Crry everett STATE wa ZIP 98201
<br /> CONTRACTOR PHONE:425-252 4402 CONTRACTOR EMAIL:ALISHA@gsheating.com
<br /> CONTRACTOR LIC.#(REQUIRED):GSHEAHC8218R CITY OF EVERETT BUSINESS LIC.#(REQUIRED):60058
<br /> PRIMARY CONTACT: DOWNER ✓CONTRACTOR ❑OTHER(Please Specify)
<br /> CONTACT NAME: CONTACT PHONE:425-252-4402
<br /> ALISHA CLOGSTON CONTACT EMAIL:ALISHA@gsheating.com
<br /> AGREEMENT.:1 hereby certify that!have read and examined this application and know the same to be true and correct. All provisions of laws 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 /> local law regulating construction or the performance of construction. That 1 am authorized by the owner of this property to perform the work for which application is made and I
<br /> comply with the State Contractors Law 18.27 RCW and 296.200 WAC. City of Everett Official Use Only
<br /> PERMIT#:
<br /> ALISHA CLOGSTON E 2_co( `O S
<br /> Owner/Authorized Agent Signature Date (Revised 1/11/2019) Page 1-Application
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