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<br /> Mill
<br /> . il,.. ELECTRICAL PERMIT APPLICATION
<br /> EVERETT CITY OF EVERETT PERMIT SERVICES
<br /> 3200 CEDAR STREET,EVERETT,WA 98201
<br /> WASH INGTON (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: / ;!/ 1,i'e l - bre .1 -< BUILDING AREA: ,,, 0 0 sq ft
<br /> PROJECT TYPE: ❑ NEW CONSTRUCTION ❑ADDITION ❑ TENANT IMPROVMENT ❑ REMODEL
<br /> BUILDING USE: ❑SFR ❑TOWNHOUSE ❑ DUPLEX ❑ADU ❑ MULTI-FAMILY-#OF UNITS: ® COMMERCIAL
<br /> ELECTRICAL APPLICATION INFORMATION 8, DESCRIPTION,OF WORK
<br /> CONTRACT PRICE OF WORK:$ rr ASSOCIATED BUILDING PERMIT#(if applicable):
<br /> DESCRIBE SCOPE OF WORK: L—c,� -ty,:n L.. �r i��� c - \„ r -� 1=e ;l. � ;‘A �i
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<br /> ,:X I f C On n e-c - VC? c n,i t cc- 1' /1 k E r ,) J j, t'
<br /> THIS INSTALLATION INCLUDES THE FOLLOWING SCOPE: (SELECT ALL THAT APPLY)
<br /> LINE VOLTAGE WORK? El NO El YES-Select Scope: El Service ❑ Feeder ❑ Circuits-#: ❑ Complete Re-wire
<br /> LOW VOLTAGE WORK? ❑ NO ❑YES-#of Devices:
<br /> SELECT SCOPE(REQUIRED): ❑ Data ❑ Intercom El 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: 7 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 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: C`.$c;, I, -:I - r},.-, TENANT BUSINESS NAME(If Commercial):
<br /> OWNER MAILING ADDRESS: STREET ( J ( I5( ✓� I{ tr ,.
<br /> CITY „'G i 411 STATE I,,;• h ZIP I djo
<br /> OWNER PHONE: (-(j S-- '49 5- la OWNER EMAIL
<br /> CONTRACTOR NAME: r, = eroc ,A,,qn 1-I,�cti „y ,0,- CDn (ttt_r-'
<br /> CONTRACTOR ADDRESS: STREET S0.1 ,;)-4-01^ ii A/i„,,,
<br /> CITY S-fiQ Kt_()o STATE I v A- ZIP CI(id, 9,4
<br /> CONTRACTOR PHONE: O-(FC J- I,S 3 CONTRACTOR EMAIL: l'hr 0 r „,LN,, k e,-','1, eli y-„ +u, f, CO--,
<br /> CONTRACTOR LIC.#(REQUIRED) Tl( [ Q C,, H k 4)...3 CITY OF EVERETT BUSINESS LIC.#(REQUIRED): 644,t,CIPAi,,
<br /> PRIMARY CONTACT: DOWNER 121CONTRACTOR ❑OTHER(Please Specify)
<br /> .. _____,7i
<br /> CONTACT NAME: CONTACT PHONE: I? 0 _ -(�t - 3 ( 5 -3
<br /> `
<br /> ,).' z-'h �J f 0 c k` Mc r� CONTACT EMAIL:
<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 /> _... ,
<br /> E r v 0-. 2'0-
<br /> t______ , ,,,,_.,_ , 5
<br /> OwKr/Authorized Agent Signature Date (Revised 1/11/2019) Page 1-Application
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