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0 <br />ELECTRICAL PERMIT APPLICATION <br />CITY OF EVERETT PERMIT SERVICES <br />3200 CEDAR STREET, EVERETT, WA 98201 <br />OL /Pl d7_5_7.ri7-RR10 1 FAX 425-257-8857 1 (E) everetteps@everettwa.gov I www.everettwa.gov/permits <br />PROJECT SITE INFORMATION <br />PROJECT ADDRESS: �� - <br />BUILDING AREA: sq ft <br />PROJECT TYPE: ❑ NEW CONSTRUCTI N ❑ ADDITION 4 TENANT IMPROVMENT ❑ REMODEL <br />BUILDING USE: Ehr—FR ❑ TOWNHOUSE ❑ DUPLEX ❑ ADU ❑ MULTI -FAMILY - # OF UNITS: ❑ COMMERCIAL <br />ELECTRIC L APP41C4N;:1NI*.+QRMATION B DESCRIPTION OF, WORK .; <br />CONTRACT PRICE OF WORK: $ <br />ASSOCIATED BUILDING PERMIT # (if applicable): <br />DESCRIBE SCOPE OF WORK: odl— <br />THIS INSTALLATION INCLUDES THE FOLLOWING SCOPE: (SELECT ALL THAT APPLY) <br />LINE VOLTAGE WORK? ❑ NO ❑ YES - Select Scope: ❑ Service ❑ Feeder ❑ Circuits-#: ❑ Complete Re -wire <br />LOW VOLTAGE WORK? ❑ NO ❑ 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�COMPLU OCE," <br />IS THIS PERMIT EDUCATION, INSTITUTIONAL, HEALTH AND/OR PERSONAL CARE FACILITIES: NO L3 YES - 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• O ❑YES -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 />Elwithout 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.INFORMATION <br />OWNER NAME: L� . �� TENANT BUSINESS NAME If Commercial <br />OWNER MAILING ADDRESS: STREET 91 <br />STATE , ZIP <br />CITY <br />OWNER PHONE: <br />OWNER EMAIL: <br />CONTRACTOR NAME: f 19 <br />/ <br />CONTRACTOR ADDRESS: STREET <br />CITY STAT ZIP 216 <br />CONTRACTOR PHONE <br />CONTRA TOR EMAIL: <br />CONTRACTOR LIC. #(REQUIRED): , ,QCITY OF EVERETT BUSINESS LIC #(REQUIRED) <br />PRIMARY CONTACT: ❑ OWNER XCONTRACTOR ❑ OTHER (Please Specify) a <br />CONT T AME: <br />CONTACT PHONE: ® & — 6 -Os- <br />CONTACT EMAIL: d �S 7 <br />of laws and ordinances oovemino this <br />AGREEMENT., I hereby cemry t ' na <br />type of work will be complete whether <br />local law regulating constr (tion or the <br />comply with the State Co ractors Law) <br />WN <br />orized Agent <br />e read and examuieu una apph—u-, <br />pecified 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 />erformance of construction. That I am authorized by the owner of this property to perform the work for which application is made and/ <br />8.27 RCW and 296.200 WAC. City of Everett Official Use Onl <br />PERMIT #: <br />E <br />Date (Revised 1/1112019) age 1-Application <br />