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ELECTRICAL PEFtillll°T APPLICATION EVERETT 32CITY OF EVERETT PERMIT SERVICES 00 CEDAR STREET, EVERETT, WA 98201 (P) 425-257-8810 1 FAX 425-257-8857 1 (E) everetteps@everettwa.gov I www.everettwa.gov/permits PROJECT;�1TEJNFORMA't 110N PROJECT ADDRESS: .; (O / BUILDING AREA: sq ft PROJECT TYPE: ❑ NEW CONSTRUCTION ❑ ADDITION ❑ TENANT IMPROVMENT ❑ REMODEL ' BUILDING USE: ❑ SFR ❑ TOWNHOUSE ❑ DUPLEX ❑ ADU ❑ MULTI -FAMILY - # OF UNITS: ❑ COMMERCIAL ELECTRICAL APPLICATION IN ORMATI4N.$F`DESGRlRT1ON=OP WORK CONTRACT PRICE OF WORK: $ ASSOCIATED BUILDING PERMIT # (if applicable): DESCRIBE SCOPE OF WORK: THIS INSTALLATION INCLUDES THE FOLLOWING SCOPE: (SELECT ALL THAT APPLY) LINE VOLTAGE WORK? ❑ NO ❑ YES - Select Scope: ❑ Service ❑ Feeder ❑ Circuits-#: ❑ Complete Re -wire LOW VOLTAGE WORK? ❑ NO ❑ YES- # of Devices: SELECT SCOPE (REQUIRED): ❑ Data ❑ Intercom ❑ Thermostat ❑ Audio ❑ Secure Access ❑ Security System ❑ 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. ❑ Other (List All): CODE gPMPL1ANCE; IS THIS PERMIT EDUCATION, INSTITUTIONAL, HEALTH AND/OR PERSONAL CARE FACILITIES: NO YES -- See Below & Pg. 2 ❑ By checking this box, 1 am stating that I have read and understand all of WAC 296-4613-900, 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: ❑NO DYES -See Below & Pg. 3 Pursuant to RCW 19.28.261, property owners and leaseholders cannot perform electrical work on buildings for rent, sale, or lease ❑ without the proper electrical licensing and certification, or exemption. By checking this box, I am stating that 1 have completed and See Page 3 signed the AFFIDAVIT on page 3 of this application to receive an exemption from this licensing/certification requirement. OWNER NAME: ` TENANT BUSINESS NAME (If Commercial): r— OWNER MAILING ADDRESS: STREET c A 6 - t " ,• / f CITY STATE t.'CJ L"C` ZIP OWNER PHONE: OWNER EMAIL: CONTRACTOR NAME: roY CONTRACTOR ADDRESS: STREET CITY STATE lol.! % T•- ZIP CONTRACTOR PHONEL — i l CONTRACTOR EMAIL: CONTRACTOR LIC. #(REQUIRED): CITY OF EVERETT BUSINESS LIC #(REQUIRED) _ ... �.._ .. __ � ..... PRIMARY CONTACT._........... DOWNER ❑CONTRACTOR ❑OTHER (Please Specify) CONTACT NAME: CONTACT PHONE: G' CONTACT EMAIL: .. .. .. ,. _ -__ .._.._ _65_�.......:..:...... s.,•.,.. ...,4 ...din�n nnvorninn chic .... AGREEMENT: I hereby cerury Mari nave reaa anc exammeu finis app iuduun dnu wwu u- a iio - �& u6 r•_• • � � - - --..._..___ 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/ comply with the State Contractors Law 18.27 RCW and 296.200 WAC. City of Everett Official Use Only PERMIT #: Owner/A orized Agent Signature Date (Revised 1/1112019) Page 1-Application