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LI CTRICAL PERMIT APPLIATION
<br /> EVERETT CITY OF EVERETT PERMIT SERVICES
<br /> 3200 CEDAR STREET,EVERETT,WA 98201
<br /> WASHINGTON (P)425-257-8810 I FAX 425-257-8857 I(E)everetteps@everettwa.gov I www.everettwa,gov/permits
<br /> PROJECT SITE INFORMATION
<br /> PROJECT ADDRESS: •;J 2( Co(I7 t/ A E .F ii cf r L+f" BUILDING AREA: sq ft
<br /> PROJECT TYPE: ❑ NEW CONSTRUCTIONIn ❑ADDITION N-TENANT IMPROVMENT ❑ REMODEL
<br /> BUILDING USE: ❑SFR El TOWNHOUSE ❑ DUPLEX ❑ADU ❑ MULTI-FAMILY-#OF UNITS: COMMERCIAL
<br /> ELECTRICAL APPLICATION INFORMATION & DESCRIPTION OF WORK
<br /> CONTRACT PRICE OF WORK: $ 2 . c)00,2L) ASSOCIATED BUILDING PERMIT#(if applicable):
<br /> DESCRIBE SCOPE OF WORK: 13., !L(k CA-0 LC-b -_ C c I Z-r a- -3 c;L,.+1 i'CS t-{,ici-1- 6::r-
<br /> Cu. r cr -lv 0 /1 AGi VVI G',( 1.')0.V -' ,}iV (',r:4 t:r 5l..✓l C.� Po:�('
<br /> THIS INSTALLATION INCLUDES THE FOLLOWING SCOPE: (SELECT ALL THAT APPLY)
<br /> LINE VOLTAGE WORK? El NO P. YES-Select Scope: ❑ Service ❑ Feeder ❑Circuits-#: ❑ Complett=Re-wire
<br /> LOW VOLTAGE WORK? jR NO El YES-#of Devices:
<br /> SELECT SCOPE(REQUIRED): ❑ Data ❑ Intercom ❑Thermostat ❑Audio El 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: El NO ,,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: ENO EYES-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 /> CONTACTI INFORMATION
<br /> OWNER NAME: rl-c;;:ct6.'LcC 4 5-,G --tLi. 1 /',��nnk'Cll�'L:I TENANT BUSINESS NAME(If Commercial):
<br /> OWNER MAILING ADDRESS: STREET f Et.i Ll,,,c( At y S 4L' it 9r'l� /j
<br /> CITY J?c.t itj STATE CC17't ZIP �I (.1.�3
<br /> OWNER PHONE: OWNER EMAIL:
<br /> CONTRACTOR NAME: V'EC-'A t 1,Lh';c_ ci_ i e_,:.6,e1,( n -i L L C_
<br /> CONTRACTOR ADDRESS: STREET `c Co IA{ r(^ 4 U. ej
<br /> CITY ,J L.C.:..1 L f I 1 C. STATE ii.,I 4 ZIP 1 e i 6 P,
<br /> CONTRACTOR PHONE: '2 LC:,- L(3ti 5 2%C, CONTRACTOR EMAIL:
<br /> CONTRACTOR LIC.#(REQUIRED):V C.A E Er 2-( L.,Cs< CITY OF EVERETT BUSINESS LIC,#(REQUIRED): Gv l{g'S
<br /> PRIMARY CONTACT: DOWNER ['CONTRACTOR [OTHER(Please Specify) f^i:.tj 6:4:,14,:-,-..1 re:-tr6-.,i, -I
<br /> CONTACT NAME: CONTACT PHONE: 2C(,:, ,a L._ 3 i
<br /> _SASii1 Sc0GE..;,,.j.1L CONTACT EMAIL: 3,95yv►: SCt-il:';77;,t.) ', z.,1 , V 2 4 .CC,'"1
<br /> 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
<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. 7 RCW and 296.200 WAC. City_of Everett Official Use Only
<br /> PERMIT#:
<br /> E2\c — l?
<br /> ner/Au orized Agent Signatlare Date ! Z ` (Revised 1/11/2019) Page 1-Application
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