607 SE EVERETT MALL WAY SUITE N ISLANDERS STORE 2021-09-22

• *ELECTRICAL PERMIT APPLICAT ION EVERETT CITY OF EVERETT PERMIT SERVICES 3200 CEDAR STREET, EVERETT,WA 98201 ` WASHINGTON (P)425-257-8810 i FAX 425-257-8857 j(E)everetteps@everettwa.gov waw.everettvva.govlpermits • PROJECT SITE'INFORMATION PROJECT ADDRESS:wo1 SE evecc4-}- AS1 Way cS-4. 14 BUILDING AREA: sq ft PROJECT TYPE: ❑ NEW CONSTRUCTION ❑ADDITION / TENANT IMPROVMENT ❑ REMODEL BUILDING USE: ❑SFR ❑ TOWNHOUSE El DUPLEX LI ADU ❑ MULTI-FAMILY-#OF UNITS: OMMERCIAL ELECTRICAL APPLICATION INFORMATON A DESCttiPTiON OF WORK ' CONTRACT PRICE OF WORK: $ 05,CO IASSOCIATED BUILDING PERMIT#(if applicable): DESCRIBE SCOPE OF WORK: ins-- ) ( i) LED oil cLnne.t ‘e-'er Sign d 1 Sp�lty THIS INSTALLATION INCLUDES THE FOLLOWING SCOPE: (SELECT ALL THAT APPLY) LINE VOLTAGE WORK? 560 ❑YES-Select Scope: ❑ Service ❑ Feeder ❑Circuits-#: ❑ Complete Re-wire LOW VOLTAGE WORK? El NO AYES-#of Devices: I SELECT SCOPE(REQUIRED): ❑ Data ❑ Intercom ❑ Thermostat ❑Audio El Secure Access ❑ Security System El Fire Alarm-Installations under this permit only include electrical wiring rough-in of the system.An additional Fire Alarm Permit is required for review of device location and installation approval. rj Other(List All): 51 g1n COPE COMPLIANCE • IS THIS PERMIT EDUCATION,INSTITUTIONAL, HEALTH AND/OR PERSONAL CARE FACILITIES: 710 El YES--See Below& Pg 2 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 of this application(see next page),AND Plan Review is NOT required because I meet all of the following sub sections that do not See Page 2 require Plan Review. ARE YOU AN OWNER PERFORMING WORK AS THE CONTRACTOR WITHOUT ELECTRICAL LICENSURE: ►ti 0 EYES-See Below&Pg.3 R7 Pursuant to RCW 19.28.261, property owners and leaseholders cannot perform electrical work on buil.ings for rent, sale,or lease without the proper electrical licensing and certification,or exemption. By checking this box, I am stating that I have completed and See Page 3 signed the AFFIDAVIT on page 3 of this application to receive an exemption from this licensing/certification requirement. y CONTACT INFORMATION OWNER NAME: Lone L.,e)hv10� TENANT BUSINESS NAME(If Commercial): IS \ande►-$ 31-O re. OWNER MAILING ADDRESS: STREET ‘201 Evere A- !no,'1 Jq� STATE V V A S`b� r /y,�, eiTv �v�re-i--I- ZIP C� 62,0 V 1 OWNER PHONE: OWNER EMAIL: CONTRACTOR NAME: 3 jQ T S3ri Servt c-CS CONTRACTOR ADDRESS: STREET J(0212. Boi-bem } i&) , _F2,31 CRY YY11 I1 Cre e!C. STATE NJ A- ZIP 1 a 01 2 CONTRACTOR PHONE: 1125.330. 8)lc ) CONTRACTOR EMAIL: b b-1'S 19Y1s @a YY1S n, Corn CONTRACTOR LIC.#(REQUIRED): BTSI S1'. 9O q CITY OF EVERETT BUSINESS LIC.#(REQUIRED): 0 55 J O ! PRIMARY CONTACT: DOWNER CONTRACTOR EOTHER(Please Specify) CONTACT NAME: CONTACT PHONE: 425.-33o, S)1 O Fran Gon2o�s CONTACT EMAIL: bbtS)Cns()rnsn .Com AGREEMENT I hereby certify that I have read and examined this application and know the same to be true and correct. All provisions of laws and ordinances governing this 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 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 comply with the State Contractors Law 18.27 RCW and 296.200 WAC. City of Everett Official Use Only PERMIT#: De) . a', .247� Euo� • l l � Owner uthori d A "nt Signature Date (Revised 1/11/2019) -Page I-Appiication Z