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0 <br />J <br />EVERETT <br />WASHINGTON <br />CITY OF EVERETT PERMIT SERVICES <br />3200 CEDAR STREET, EVERETT, WA 98201 <br />(P) 425-257-8810 1 FAX 425-257-8857 1 (E) everetteps@everettwa.gov I www.everettwa.gov/permits <br />®® _ ors:_."�,..�.�.-,.R..,�_......�.—,... ............_ <br />PROJECT SITE INFORMATION <br />PROJECT ADDRESS: Z l <br />�-I - a <br />BUILDING AREA: scI ft <br />PROJECT TYPE: ❑ NEW CONSTRUCTION ❑ ADDITION CR TENANT IMPROVMENT ❑ REMODEL <br />BUILDING USE: KI SFR ❑ TOWNHOUSE ❑ DUPLEX ❑ ADU ❑ MULTI -FAMILY - # OF UNITS: ❑ COMMERCIAL <br />ELECTRICAL APPLICATION INFORMATION & DESCRIPTION OP WORK <br />CONTRACT PRICE OF WORK: $ . 7 <br />ASSOCIATED BUILDING PERMIT # (if applicable): <br />DESCRIBE SCOPE OF WORK: R IC -AC in r 4 - Y �' P r:o <br />1�0�c a- -e - <br />r • k }� • � Y1 i r �� cza �' . . <br />4PV' CA ,`' <br />THIS INSTALLATION INCLUDES THE FOLLOWING SCOPE: (SELECT ALL THAT APPLY) <br />LINE VOLTAGE WORK? ❑ NO K YES - Select Scope: ❑ Service ❑ Feeder 7R] Circuits-#: ❑ Complete Re -wire <br />LOW VOLTAGE WORK? gNO ❑ 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 />CODE�COMPLIANCE <br />IS THIS PERMIT EDUCATION, INSTITUTIONAL, HEALTH AND/OR PERSONAL CARE FACILITIES: NO YES -- See Below & Pg. 2 <br />❑ By checking this box, I am stating that I have read and understand all of WAC 296-466-900, 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 NYES -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. <br />CONTACT!INEORMATION <br />OWNER NAME: 1vl �• TENANT BUSINESS NAME (If Commercial): <br />OWNER MAILING ADDRESS: STREET Z <br />CITY vV p r-C <br />STATE ZIP W <br />t� <br />OWNER PHONE:�1 y i z <br />- y -LI Z C)'S <br />OWNER EMAIL: b w -V" 1 1 hZ ve -C <br />CONTRACTOR NAME: P <br />CONTRACTOR ADDRESS: STREET <br />CITY STATE ZIP <br />CONTRACTOR PHONE: <br />CONTRACTOR EMAIL: <br />CONTRACTOR LIC. #(REQUIRED): <br />CITY OF EVERETT BUSINESS LIC. #(REQUIRED): <br />PRIMARY CONTACT: ZbWNER []CONTRACTOR ❑OTHER (Please Specify) <br />CONTACT NAME: j <br />r 1 a,n �Y►� 1 I <br />CONTACT PHONE: e-'j _��1-1 JI <br />CONTACT EMAIL: i Z e )>7(' e <br />AGREEMENT., I hereby certify that I have read and examined this application and Know the same to oe true ana correct. Au provisions or laws and ordinances yovenuny uus <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 I 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 />zc'-Zc, E `0�— 0(04 <br />L) net/Authorised Agent Signature Date (Revised 1/1112019) Page 1-Application <br />r4er <br />1 I -Oqk.,. <br />