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10 6 <br />ELECTRICAL PERMIT APPLICATION <br />EVERETT <br />WCCNINrTnN <br />CITY OF EVERETT PERMIT SERVICES <br />3200 CEDAR STREET, EVERETT, WA 98201 <br />(P) 425-257-8810 i FAX 425-257-8857 1 (E) everetteps@everettwa.gov I www.everettwa.gov/permits <br />`PROJECT'311TS NF.ORMATI©N <br />PROJECT ADDRESS: <br />BUILDING AREA: sq ft <br />PROJECT TYPE: ❑ NEW CONSTRUCTION ❑ ADDITION ❑ TENANT IMPROVMENT Z REMODEL I /.j /' L r % <br />BUILDING USE: P 'SFR ❑ TOWNHOUSE ❑ DUPLEX ❑ ADU ❑ MULTI -FAMILY - # OF UNITS: ❑ COMMERCIAL <br />ELECTRECAL APRLICATIQN :INFORMATION .8 DESCRPTfON OF, wOK .... . <br />CONTRACT PRICE OF WORK: $ <br />ASSOCIATED BUILDING PERMIT # (if applicable): <br />DESCRIBE SCOPE OF WORK: t ' l 1 1 <br />THIS INSTALLATION INCLUDES THE FOLLOWING SCOPE: (SELECT ALL THAT APPLY) <br />LINE VOLTAGE WORK? ❑ NO [ YES - Select Scope: ❑ Service ❑ Feeder Circuits-#:_�_ ❑ Complete Re -wire <br />LOW VOLTAGE WORK? [71 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 />o + oNIP'«A1NGE ... .:.. , <br />IS THIS PERMIT EDUCATION, INSTITUTIONAL, HEALTH AND/OR PERSONAL CARE FACILITIES: 29.No LJ 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: EZNO DYES -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 />,:.. CaNITA - TT,fNFORMATIE N ;; <br />OWNER NAME: j`I; U S S " L L f' G-U- -ek TENANT BUSINESS NAME (If Commercial): <br />OWNER MAILING ADDRESS: STREET 1 1 U _ Z o A- V <br />1i <br />� I-•' t� � I CITY STATE ZIP <br />T—(i t. R <br />OWNER PHONE: y J % `I 4S 4 <br />OWNER EMAIL: I N Re Ce S� <br />CONTRACTOR NAME: Z Zl Xr` e6 <br />CONTRACTOR ADDRESS: STREET j LI C /-I e S r Yt., T <br />CITY A- L STATE ZIP <br />CONTRACTOR PHONE: Y S 3 S % Z i 9y <br />CONTRACTOR EMAIL: C L I} R 64L L L e G 72 1.G (V )40 7-M A, L <br />CONTRACTOR LIC. #(REQUIRED): C A- 5 S I' CITY OF EVERETT BUSINESS LIC. #(REQUIRED): 6i Ll O <br />PRIMARY CONTACT: [I OWNER ®CONTRACTOR ❑OTHER (Please Specify) <br />CONTACT NAME: <br />-e I`+ 1.1) CA L- p A �i a' <br />CONTACT PHONE: L Z S 3 S i 2 9 <br />CONTACT EMAIL: CA- L A y p r A - L e G'r (� <br />AGREEMENT: I hereby certity that I have read and examined this application and Know the same to be true and correct. Ha provisions ui raws anu ururndncas yuvCnuny uus <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/ <br />comply with the State Contractors Law 18.27 RCW and 296.200 WAC. City of Everett Official Use Only <br />PERMIT #: <br />Owner/Authorized Agent Signature Date (Revised 111112019) Page 1-Application <br />9LG <br />