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1110 • <br /> LECT I AL PERMIT APPLICATION <br /> EVERETT 32 CITY OF EVERETT PERMIT SERVICES <br /> 00 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: lZ 1 Co W40,16►A Wil t. Evt reA , fl BUILDING AREA: sq ft <br /> PROJECT TYPE: ❑ NEW CONSTRUCTION ❑ADDITION ❑ TENANT IMPROVMENT Lif REMODEL <br /> BUILDING USE: ©SFR ❑TOWNHOUSE ❑ DUPLEX ❑ADU ❑ MULTI-FAMILY-#OF UNITS: ❑ COMMERCIAL <br /> ELECTRICAL APPLICATION INFORMATION & DESCRIPTION OF WORK <br /> CONTRACT PRICE OF WORK:$ 2.1)00 ASSOCIATED BUILDING PERMIT#(if applicable): <br /> DESCRIBE SCOPE OF WORK: Add rtA) a 2.0 A one 12.0 = - <br /> Up 9 rG 3:et q VI C. it.actim �: IA S <br /> THIS INSTALLATION INCLUDES THE FOLLOWING SCOPE: (SELECT ALL THAT APPLY) <br /> LINE VOLTAGE WORK? ❑ NO 2 YES-Select Scope: ❑ Service ❑ Feeder Circuits-#: I ❑ 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 /> CODE COMPLIANCE <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. rr�I <br /> ARE YOU AN OWNER PERFORMING WORK AS THE CONTRACTOR WITHOUT ELECTRICAL LICENSURE:t-I NO EYES-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: arm) co Vr/ TENANT BUSINESS NAME(If Commercial): <br /> OWNER MAILING ADDRESS: STREET Z,Z II CO tV Yrt bi N F <br /> CITY 1i vE f t }, STATE W h ZIP q%7.0 3 <br /> OWNER PHONE: y Z i O%2-3 OWNER EMAIL: 1p gad c e1 10$41 d COM <br /> CONTRACTOR NAME: AMped [4( r( C. an) Y (t1ot et C0.1 <br /> CONTRACTOR ADDRESS: STREET (;O°I i3omitvtllt Ai . 5vt4t, 7.O <br /> CITY 0 V•0 Yrt 1 S rl STATE tjk, It ZIP 9 g Z,q U' <br /> CONTRACTOR PHONE: 3(,0 VI 2171, CONTRACTOR EMAIL: vie)%#. IcvN V+CW►;f'Iva <br /> CONTRACTOR LIC.#(REQUIRED) A rn td 9 O1 d r CITY OF EVERETT BUSINESS LIC.#(REQUIRED) O N Y 7 I Z. <br /> PRIMARY CONTACT: DOWNER CONTRACTOR ❑OTHER(Please Specify) <br /> CONTACT NAME: CONTACT PHONE: Z O 4 , Zq , I I if Sr <br /> M act WC CONTACT EMAIL: hn iIUlr W 6) cA0ln 101 i S V yA 11 , 0 V+1 <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 lam authorized by the owner of this property to perform the work for which application is made and I <br /> comply with the Stat tractors Law 18.27 RCW and 296.200 WAC. City of Everett Official Use Only <br /> PERMIT#: <br /> A./ZoZZ zG ; E 2301 _\ � <br /> 9 9 <br /> Owner/Auth rized Agent Signature Date (Revised 1/11/2019) Page 1-Application <br />