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0 0 <br />® ELECTRICAL PERMIT APPLICATION11 <br />CITY OF EVERETT PERMIT SERVICES <br />EVERETT 3200 CEDAR STREET, EVERETT, WA 98201 <br />WASHINGTON (P)425-257-8810 1 FAX425-257-8857 1(E)everetteps@everettwa.govI www.everettwa.gov/permits <br />PROJECT SITE INFORMATION <br />PROJECT ADDRESS: <br />BUILDING AREA: G'tJ sq f't <br />PROJECT TYPE: El NEW CONSTRUCTION ❑ ADDITION El IMPROVMENT ❑_ REMODEL <br />BUILDING USE: ❑ SFR ❑ TOWNHOUSE ❑ DUPLEX ❑ ADU ❑ MULTI -FAMILY - # OF UNITS: y` .COMMERCIAL <br />ELECTRICALAPPLICATION INFORMATION & DESCRIPTION OF WORK <br />CONTRACT PRICE OF WORK: $ 0 6 <br />ASSOCIATED BUILDING PERMIT # (if applicable): <br />DESCRIBE SCOPE OF WORK: ��� , �,„ u�/ f L• / i �c u e �✓ <br />12a ✓o G <br />THIS INSTALLATION INCLUDES THE FOLLOWING SCOPE: (SELECT ALL THAT APPLY) <br />LINE VOLTAGE WORK? ❑ NO [ .YES - Select Scope: ❑ Service ❑ Feeder ❑ Circuits-#: -R' ❑ 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 COMPLIANCE <br />IS THIS PERMIT EDUCATION, INSTITUTIONAL, HEALTH AND/OR PERSONAL CARE FACILITIES: _. NO EIYES -- 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: []NO ❑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 />without the proper electrical licensing and certification, or exemption. By checking this box, I am stating that 1 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: C y,� TENANT NAME (If Commercial): <br />/BUSINESS <br />OWNER MAILING ADDRESS: STREET <br />CITY -�' L' -�� STATE ZIP 2 61" <br />OWNER PHONE: <br />OWNER EMAIL: <br />CONTRAC TORNAME: e",.` C <br />CONTRACTOR ADDRESS: STREET <br />CITY (� e " STATE ✓ ZIP <br />CONTRACTOR PHONE:'Y2- -3 Y <br />�►' <br />CONTRACTOR EMAIL: r V f �, �T/�/I— �,/; i✓�'1 <br />CONTRACTOR LIC. #(REQUIRED): L E �� CITY OF EVERETT BUSINESS LIC. #(REQUIRED): <br />PRIMARY CONTACT: DOWNER. � <br />.CONTRACTOR MOTHER (Please Specify) <br />CONTACT NAME: / <br />7?,n1 j j C ��,iY7 l�clk <br />CONTACT PHONE: �/Z <br />CONTACT EMAIL: f �1�,�j, <br />AGRLLMLNI: I hereby certify that I have read and examined this appucatton and Know me same to oe true anu correct. Hu piuwstvns of taws anu vruutm,ccs ywr „, y „� <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/ 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 />9/a/9 <br />I E nod <br />--OS` <br />/�/'% <br />Date <br />(Revised 111112019) <br />Page 1-Application <br />Owner/Authorized Agent Signature <br />