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<br /> mg EECTRICAL PERMIT APPL1OTION
<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: .Z C., ` 7` i-Q,-IA q,,,1/4r<t . BUILDING AREA: sq ft
<br /> PROJECT TYPE: ❑ NEW CONSTRUCTION ❑ADDITION ETENANTIMPROVMENT l REMODEL
<br /> BUILDING USE: L SFR El TOWNHOUSE El DUPLEX ❑ADU ❑ MULTI-FAMILY-#OF UNITS: ❑COMMERCIAL
<br /> ELECTRICAL APPLICATION INFORMATION & DESCRIPTION OF WORK
<br /> CONTRACT PRICE OF WORK:$ 1 j o a ASSOCIATED BUILDING PERMIT#(if applicable):
<br /> DESCRIBE SCOPE OF WORK: 1153-0% i .inl S:r v,Ce .Se_p - c-1-0 n. H a u;e_ -+a
<br /> 3a.rb"nl'.. 12.e_ - us/, rG Gvarrr,x)l lr, IA/Q \ram_ .> Fir4S c./LA L ti5nc_ �c'a-vA 5('iVir
<br /> +- le \y Far )hu , /i c-,/<,.cri_..
<br /> THIS INSTALLATION INCLUDES THE FOLLOWING SCOPE: (SELECT ALL THAT APPLY) P
<br /> LINE VOLTAGE WORK? CI NO ,YES-Select Scope: IN Service El Feeder ❑ Circuits-#: 10 tK1 Complete Re-wire
<br /> LOW VOLTAGE WORK? 0,NO El YES-#of Devices:
<br /> SELECT SCOPE(REQUIRED): El Data ❑ Intercom Cl Thermostat ❑Audio El Secure Access El 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 /> n Other(List All):
<br /> CODE COMPLIANCE
<br /> IS THIS PERMIT EDUCATION,INSTITUTIONAL,HEALTH AND/OR PERSONAL CARE FACILITIES: El NO El YES--See Below&Pg.2
<br /> I I 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: ❑NOXYES-See Below&Pg. 3
<br /> 0 Pursuant to RCW 19.28.261,property owners and leaseholders cannot perform electrical work on building 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 /> CONTACT INFORMATION
<br /> OWNER NAME: r r P I O.,,,,,,{r- TENANT BUSINESS NAME(If Commercial):
<br /> OWNER MAILING ADDRESS: sTREET (, i? i-,,)-el r,,,,t, i. A-'./r'
<br /> r
<br /> crry �'' kf e.-t >•' STATE ;,,
<br /> OWNER PHONE: . 1-t3 `1-()`i OWNER EMAIL: ,x...'1,.,,, �; ) W y t A -._,.) ..- ,. (<).^'‘
<br /> CONTRACTOR NAME:
<br /> CONTRACTOR ADDRESS: STREET
<br /> CITY STATE ZIP
<br /> CONTRACTOR PHONE: CONTRACTOR EMAIL:
<br /> CONTRACTOR LIC.#(REQUIRED): CITY OF EVERETT BUSINESS LIC.#(REQUIRED):
<br /> PRIMARY CONTACT: +OWNER ❑CONTRACTOR ❑OTHER(Please Specify)
<br /> CONTACT NAME: CONTACT PHONE: 55.4\ - Z(''') -• I ,,<--I y
<br /> r . € r t v M. u' CONTACT EMAIL: . , U InJ y 1 i.<,
<br /> AGREEMENT:I hereby certify that I have read and examined this application and know the same to be true and co . 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 lam 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 /> / El---------- (cy pj-1/2,,bV\
<br /> 1 i0 - l9II
<br /> Owner/Authorized AJentSignatdrd Date (Revised 1/11/2019) Page 1-Application
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