|
• •
<br /> in ELECTRICAL PERMIT APPLICATION
<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: °—(&_t kej,, (a_S i/1 6 11.6 C✓ei 9�`BUILDING AREA: sq ft
<br /> SS�
<br /> PROJECT TYPE: 1�.�.1 NEW CONSTRUCTION ❑ADDITION ❑TENANT IMPROVMENT ❑ REMODEL
<br /> BUILDING USE: ❑SFR El TOWNHOUSE ❑ DUPLEX El ADU El MULTI-FAMILY-#OF UNITS: ❑ COMMERCIAL
<br /> ELECTRICAL APPLICATION INFORMATION & DESCRIPTION.OF WORK
<br /> CONTRACT PRICE OF WORK: $- Z, 0 2 . 62 L7 ASSOCIATED BUILDING PERMIT#(if applicable): rs 171(-0.730
<br /> DESCRIBE SCOPE OF WORK: t,te S rad e Ex;S t-i AS 6/ecf r Ca( 5.Y•S M i A Pre✓:f0'h5
<br /> G6 ti 5i. ti i( er- G.Lci7 ifu 6+a,tC. con✓ai'Sw t,),r\ S"C P- •
<br /> THIS INSTALLATION INCLUDES THE FOLLOWING SCOPE: (SELECT ALL THAT APPLY)
<br /> LINE VOLTAGE WORK? El NO E YES-Select Scope: 1❑ Service ElFeeder ElCi (sit: 3 ❑ Complete Re-wire
<br /> LOW VOLTAGE WORK? ❑ NO I YES-#of Devices: 'f „„1'
<br /> SELECT SCOPE(REQUIRED): El Data El Intercom ❑Thermostat El Audio ❑Secure Access M 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: El 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: ENO EIYES-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 /> CONTACT INFORMATION
<br /> OWNER NAME: i.),�-, C r• 9 bE't;f-(C.ii, -, t+ ' TENANT BUSINESS NAME(If Commercial):
<br /> OWNER MAILING ADDRESS: STREET 630 6 ('7C CI' S t (.��(/L'
<br /> CITY L %4//L.IS od, , (�•/, 9 6Cy7 STATE fi•I1/9 ZIP i Sg u.._3'.7
<br /> OWNER PHONE: (I a 6- 711 3/ (o 7 OWNER EMAIL: &../t deL i'-t-iS Q yIlk: / --0/11
<br /> CONTRACTOR NAME: ✓Z'-C•--
<br /> CONTRACTOR ADDRESS: STREET 6 (.2/ (76.=-6- Si- 5(...4.2
<br /> CITY L>,14 wee,, , '✓, ,IQ STATE 1/4)CC v 37
<br /> CONTRACTOR PHONE: t( -5 77L 3((..7 CONTRACTOR EMAIL: C cc11 d fr C�'"-1c®_gl44 / /cic., i o*5 2. 5%'kj/
<br /> CONTRACTOR LIC.#(REQUIRED): , vERETT BUSINESS LIC.#(REQUIRED,.
<br /> PRIMARY CONTACT: ['OWNER ❑CONTRACTOR OTHER(Please Specify) `> 77 3 q 3s6
<br /> CONTACT NAME: CONTACT PHONE: L1 Z$ 7 7.3 4 35 e, \
<br /> y b 4(.-t LI'F ,,(, CONTACT EMAIL: do , i 0 Ft'5 2 O ,Yrtt/i I ' `C-fa'.
<br /> 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
<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
<br /> PERMIT#:
<br /> fib OC _ E ,G‘c)(40 _ ,,---,,,
<br /> L---2y,
<br /> Owner/AUthorized Agent Signature Date (Revised 1/11/2019) /Page 1-Application
<br />
|