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<br /> ELECTRICAL PERMIT APPLICATION
<br /> ;,Z
<br /> /"""'` CITY OF EVERETT PERMIT SERVICES
<br /> .1 ; 3200 CEDAR STREET, EVERETT,WA 98201
<br /> (P) 5-257-8810 I FAX 425-257-8857 1(E)everetteps@everettwagov I www.everettwa.gov/permits
<br /> PROJECT ADDRESS: 6129 AGNOLIA AVE BUILDING AREA: 1232 sq ft
<br /> PROJECT TYPE: ❑ NEW CONSTRUCTION ❑ADDITION ❑TENANT IMPROVMENT ✓❑ REMODEL
<br /> BUILDING USE: ❑✓ SFR ❑TOWNHOUSE ❑ DUPLEX ❑ADU ❑ MULTI-FAMILY-#OF UNITS: ❑ COMMERCIAL
<br /> I„' i.: LFE( „ 0 > „I'�1a, ,. ..;..�,<„ Nm... .7', „ f, . ' ... „•,,.s�T.« OW ,, s�.CONTRACT PRICE OF WORK:$ 250 ASSOCIATED BUILDING PERMIT#(if applicable):
<br /> DESCRIBE SCOPE OF WORK:
<br /> ADD CIRCUIT FOR DUCTLESS HEAT PUMP INSTALLATION
<br /> THIS INSTALLATION INCLUDES THE FOLLOWING SCOPE: (SELECT ALL THAT APPLY)
<br /> LINE VOLTAGE WORK? ❑✓ NO ❑YES-Select Scope: ❑Service ❑ Feeder ❑✓ Circuits-#: 1 ❑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 /> n Ji d i yE rk
<br /> IS THIS PERMIT EDUCATION,INSTITUTIONAL,HEALTH AND/OR PERSONAL CARE FACILITIES: 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: ©NO OYES-See Below&Pg. 3W
<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 receives^ an exemption from this licensing/certification requirement.
<br /> OWNER NAME: MICHAEL DAVIS TENANT BUSINESS NAME(If Commercial):
<br /> OWNER MAILING ADDRESS: STREET 6129 MAGNOLIA AVE
<br /> c,,, EVERETT STATE WA ,,, 98203
<br /> OWNER PHONE:425-422-1850 OWNER EMAIL:mdavis426@hotmail.com
<br /> . , ,. .,, :.. _ ._"r.,. ,_,... .., .;,,,, "".z _... ,.M,,. ,.A",
<br /> CONTRACTOR NAME: C.M. HEATING INC
<br /> CONTRACTOR ADDRESS: STREET 1415 BROADWAY
<br /> CITY EVERETT STATE WA Z,P 98201
<br /> CONTRACTOR PHONE:425-259-0550 CONTRACTOR EMAIL:KAI LANA@CM HEATING.COM
<br /> CONTRACTOR LIC.#(REQUIRED): CMHEAMH877DN CITY OF EVERETT BUSINESS LIC.#(REQUIRED): 016098
<br /> PRIMARY CONTACT: [❑OWNER ❑✓CONTRACTOR DOT
<br /> HER(Please Specify)
<br /> CONTACT NAME: CONTACT PHONE:425-259-0550
<br /> KAI LANA CONTACT EMAIL:KAILANA@CMHEATING.COM
<br /> AGREEMENT.I hereby certify that/have read and examined this.appffcation and know the same to be true and correct. All provwsii©ns 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 18.27 RCW and 296,200 WAC. City of Everett Official Use Only a
<br /> PERMIT*
<br /> .f• lAvvy,"---K Y ft,. .<Y ,74,t,----,,G,C.-y, 09/04/19 E ,1(109 ci
<br /> IOwnertAuthorixed Agent Signature Date (Revised 1111 19) Page 1-Application
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