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1111 <br /> 1.2 E' TRI AL PERMIT APPLI ION,. <br /> CITY OF EVERETT PERrviiT SERVICES <br /> CEDAR STREET,&E E i'f,WA 28201 <br /> WAs)+ibcTort (P)425-257-B810 I FAX 426-257-8857'I{E)ever;atteps@eeerettiva,gowr I v.mv sveretiwa,govfpermits <br /> PROJECT ADDRESS 1II 15-"/ p 1 4\0 BUILDING AREA sq ft <br /> PROJECT TYPE: ❑NEW CONSTRUCTION Q Ate}ITiON Q TENANT IMPROVMENT l REMODEL <br /> BUILDING USE: EA SFR Ely TOWNHOUSE <br /> � El DUPLEX ❑ADU 0 McUULTI'�FAMILY-#OF UNITS: El COMMERCIAL <br /> ATI s X"PR� _ LEA ! 0 I *V & WORK <br /> ..... .,.:• ,V_.. ,"., '-�_��:... <br /> .. ..... .......... „•-.� :..r> -_ ., sue. <br /> CONTRACT PRICE OF WORK; $ L100 ASSOCIATED BUILDING PERMIT#(if applicable}': <br /> DESCRIBE SCOPE OF WORK: Ulk c d 4 i is rditieliLCA la' <br /> THIS INSTALLATION iN"CL_UDES THE FOLLOWING SCOPE: (SELECT ALL THAT APPLY) <br /> LINE VOLTAGE WORK/ EI NO Irt YES-Select Scope:El Service ❑Feeder fa Circuits-#: t El Complete Ro.wina <br /> LOW VOLTAGE WORK? 8 NO t_t YES-IA of Devices: <br /> SELECT SCOPE(REQUIFRED): El Data LI Intercom El Thermostat ❑Audio 0 Secure Access ❑Security System <br /> El 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 /> 0 Other(List All); <br /> IS THIS PERMIT EDUCATION,INSTITUTIONAL,HEALTH ANDIOR PERSONAL.CARE FACILITIES: NO U YES--See Below&Pg. 2 , <br /> By chocking this hex,I am stating that I have read and understand all of WAG 298.46B-900, selected the specific reason on page 2 <br /> of this application(see next paged AND Plan Review is NOT requited because I meet all of the following sub sections that do not <br /> Secs Page 2 require Plan Review. <br /> ARE YOU AN OWNER PERFORMING WORK AS THE CONTRACTOR WITHOUT ELECTRICAL LICENSURE: [NO DYES-See Below&Pg.3 <br /> Pursuant to HCW'19.28.261,property owners and leaseholders cannot perform electrical work on buildings for rant,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 /> sire pale I signed the AFFIDAVIT on page 3 of this application to receive an exemption from this licensing/cer lication requirement. <br /> 1 „JET <br /> OWNER NAME: S.tlylveSttr G irtUen TENANT BUSINESS NAME(If Commercial): <br /> OWNER MAILING ADDRESS STREET' 1- 5`',5 '1 £+ <br /> OWNER PHONE: 1t .43 , 0\0, !OWNER EMAIL: Its ik <br /> CONTRACTOR NAME: i?oIUt, Ft iX tt tic ire fir <br /> CONTRACTOR ADDRESS; STREET 10101,..2.f � <br /> Lily i otit" r.Lt. ..[ore _ _.... STATE V44/1" �f3 41 4, <br /> CONTRACTOR PHONE:425.11 i•11'69 'CONTRACTOR EMAIL: tiit'it`ma o UL flanit, con%ra(- Cb 1 <br /> CONTRACTOR Lie.#(REQUIRED) 16A.131ri }ts 14. CITY OF EVERETTBUSINESS LIC.#(REQUIR.ED) 40Du{Yj <br /> PRIMARY CONTACT: OW NER (CONTRACTOR ['OTHER(Please Specify) <br /> CONTACT NAME: CONTACT PHONE: 14 , . M 2 r. ty 'I il'L <br /> 4vi L+CV ErW't CONTACT EMAIL: to wit <br /> AORLLMENT::f, reby certify ttzat-1,have read.and exeretinr d M(5 anekelkin and know the satJ #o fa)true'and correct AM prnoir eiwis of laws end o zlineoces grwenh oe t is <br /> lygae of we*sieff be Gem pteted whothur:for.:llktri bur urn cv not The grarrfeng of 9 permit obeR not pr?xrtm to give aatthodry lu violate ce u n of the plOidNibns any other state or <br /> Urea law regulating cnnstruatican or the perframtsoon of ronstrectkXt That I eery eahotiarf.by the owner of this property to perform the work far which taollrrsrkta is made end <br /> carePty with the Slate COO:MONS Low la.27 ROW erxt 256200 WAG. city di Everett Official Use Only <br /> PERMIT#: <br /> tTurnerIAutho �ent Signature Date kevased fit it2O 9 Page 1 Appilcation <br />