10921 19TH AVE SE 2022-01-21 - Laserfiche WebLink

® . S ail PERMIT APPLICATION EVERETT 32 CITY OF EVERETT PERMIT SERVICES 00 CEDAR STREET,EVERETT,WA 98201 WASHINGTON (P)425-257-8810 I FAX 425-257-8857 I(E)everetteps@everettwa.gov I www.everettwa.gov/permits PROJECT_.SITE INFORMATION PROJECT ADDRESS: I Liell( 17 441 jikx., _ 3; _BUILDING AREA: sq ft PROJECT TYPE: ❑ NEW CONSTRUCTION ❑ADDITION ❑TENANT IMPROVMENT ❑ REMODEL BUILDING USE: ❑SFR ❑ TOWNHOUSE ❑ DUPLEX ❑ADU ❑ MULTI-FAMILY-#OF UNITS: COMMERCIAL ELECTRICAL APPLICATION"INFORMATION & DESCRIPTION OF WOR CONTRACT PRICE OF WORK:$ r�DD ASSOCIATE BUILDING PERMIT#(if applicable): /� DESCRIBE SCOPE OF WORK: ,6(�_ C`Y I/� 6 ez S`C3/S I V\ 1 G"r,,'t k �1"f,,►,.i f .r` THIS INSTALLATION INCLUDES THE FOLLOWING SCOPE: (SELECT ALL THAT APPLY) LINE VOLTAGE WORK? NO ❑YES-Select Scope: ❑ Service El Feeder ❑Circuits-#: ❑ Complete Re-wire LOW VOLTAGE WORK? NO ❑YES-#of Devices: SELECT SCOPE(REQUIRED): Cl Data ❑ Intercom El Thermostat ❑Audio El Secure Access ❑ Security System El 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 deviu�ocatioiccccP d installati approval. Other(ListAll): 1�,'i 6/L,- /IV(I('Vti f t : 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: O EYES-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: ,_,VW ti 1 �� TENANT BUSINESS NAME(If Commercial): e___14, V OWNER MAILING ADDRESS: STREET CITY STATE ZIP OWNER PHONE: OWNER EMAIL: CONTRACTOR NAME: 5AE___s ,,,,_.A 0 yt c r_tj( l) CONTRACTOR ADDRESS: STREET 10 / 0 7 6 1'^c ""Jy CITY I LC.' 0/61. STATE Vv1 ' ZIP e/S 145? CONTRACTOR PHONE: 2. 3-S-72 3g2)-CONTRACTOREMAIL: pia rkV 4.)e,5/Id_-5-0f iz--T5 / CO:4--( CONTRACTOR LIC.#(REQUIRED) 3 21.�- S 03 L%3! /'� I CITY OF EVERETT BUSINESS LIC.#(REQUIRED) OL,5 5 i PRIMARY CONTACT: ❑OWNER *ONTRACTOR 0-, ['OTHER(Please Specify) CONTACT NAME: CONTACT PHONE: .2,5, .- 6 0_� 3 air ) / CONTACT EMAIL: 4 NIL Vr j - ,o i U(.�"�� is✓5 I /r''�t AGREEMENT'1 hereby certify, f� W' ehave 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 Contract aw 7 RCW and 2 6:200 WAC. City of Everett Official Use Only PERMIT#: 3//'; 6 0 E _oe — Cali 4 Owner/A, oozed Agent Sigrtatu" � re Date (Revised 1/11/2019) Page 1-Application . ,.