8630 EVERGREEN WAY $1 STORE 2021-12-16

ELECTRICAL PERMIT ` PPLICATION CITY OF EVERETT PERMIT SERVICES EVERETT 3200 CEDAR STREET,EVERETT,WA 98201 WASHINGTON (P)425-257-8810 I FAX 425-257-8857 I(E)everetteps@everettwa.govI vwvw.everettwa.gov/permits PROJECT SITE INFORMATION PROJECT ADDRESS: 0(.,�'D 0,,c v- // h U,� I 46 BUILDING AREA: sq ft PROJECT TYPE: CI NEW CONSTRUCTION ❑ADDITION ❑TENANT IMPROVMENT ❑ REMODEL BUILDING USE: ❑SFR ❑ TOWNHOUSE El DUPLEX ❑ADU ❑ MULTI-FAMILY-#OF UNITS: ❑ COMMERCIAL ELECTRICAL APPLICATION INFORMATION & DESCRIPTION OF WORK CONTRACT PRICE OF WORK:$ oo ASSOCIATED BUILDING PERMIT#(if applicable): DESCRIBE SCOPE OF WORK: �cv,v�eci- L�Crrs+tY� 5-cr rircv t4- -b sir 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 El Intercom El Thermostat ❑Audio El 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 COMPLIANCE IS THIS PERMIT EDUCATION,INSTITUTIONAL, HEALTH AND/OR PERSONAL CARE FACILITIES: NO ❑ YES--See Below&Pg.2 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 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 ['YES-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 I have completed and See Page 3 signed the AFFIDAVIT on page 3 of this application to receive an exemption from this licensing/certification requirement. CONTACT INFORMATION OWNER NAME: '_:', LU -4j,, (LW on+.0-14,,,e,1„-f LLc-)TENANT BUSINESS NAME(If Commercial): OWNER MAILING ADDRESS: STREET 863D •Eki-ev e-v t, \-1 I� cry ve-4— STATE n 4- ZIP OWNER PHONE: OWNER EMAIL: L,w,1 �i1i;)7 dVt�1J tLL � I (Lw1 CONTRACTOR NAME: it•)N-(.1-e- S S l ',A,A.t,•� USIA I1,(C-) CONTRACTOR ADDRESS: STREEYFs III //w`/ CITY �yKv,�. /� STATE iwVNC ZIP ea(;h9• — CONTRACTOR PHONE: t'S 7LM-G7.h-o CONTRACTOR EMAIL: Ce'"1 CONTRACTOR LIC-#(REQUIRED) , t 4t 3 5' CITY OF EVERETT BUSINESS LIC.#(REQUIRED) U ® PRIMARY CONTACT: DOWNER CONTRACTOR ['OTHEROTHER.. (Please S peci fy) �... CONTACT NAME: CONTACT PHONE: y2 7t —D76 D i ,n CONTACT EMAIL: iVL� e L�^ i�S'i '1.S• --el-- 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 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 I comply with the State Contractors Law 18.27 RCW and 296.200 WAC. City of Everett Official Use Only PERMIT#a Owner/Authorized Agent Signature Date (Revised 1/11/2019) Page 1-Application