|
\,-e `ir- • N.0
<br /> is .-e_`A `P 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 /> ' .. PROJECTSITEiNFORMATION
<br /> PROJECT ADDRESS: 312 0 A.k4,.. 4 l(k1 Li BUILDING AREA: 0 ' sq ft
<br /> PROJECT TYPE: ❑ NEW CONSTRUCTION ❑ADDITION A TENANT IPROVMENT ❑ REMODEL
<br /> BUILDING USE: ❑SFR ❑TOWNHOUSE ❑ DUPLEX ❑ADU ❑ MULTI-FAMILY-#OF UNITS: ifEICOMMERCIAL
<br /> :ELECTRICAL APPLICATION INFFORMIATION &: DESCRIPTIONI,VF`WORK , ..
<br /> CONTRACT PRICE OF WORK:$ 16-0Ca' ASSOCIATED BUILDING PERMIT#(if applicable):
<br /> DESCRIBE SCOPE OF WORK: ' ;54
<br /> � q( cly cv,,..) el I, -" C AS 1,, 4_e(r'7-c),'i/44 j-,ht+ 5
<br /> W,`, l.%A' C1 ('OOAL.Mv,,,',./y/ 400,ti,
<br /> THIS INSTALLATION INCLUDES THE FOLLOWING SCOPE: (SELECT ALL THAT APPLY)
<br /> LINE VOLTAGE WORK? E NO rrr❑YES-Select Scope:III Service
<br /> Service CI Feeder ❑Circuits-#: CI Complete Re-wire
<br /> LOW VOLTAGE WORK? ❑ NO t l YES-#of Devices: (
<br /> SELECT SCOPE(REQUIRED): Data / `❑ Intercom ❑Thermostat El 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 /> .., :CQDW,COMPLIANCE
<br /> IS THIS PERMIT EDUCATION,INSTITUTIONAL,HEALTH AND/OR PERSONAL CARE FACILITIES: E1 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: K 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: TENANT BUSINESS NAME(If Commercial): ( )S,A;( he 1Ati��
<br /> OWNER MAILING ADDRESS: STREET 3 ( Z j-- (-)A ke 5 ,Q '
<br /> 6 CotaiN ,,h 464.
<br /> CITY t;.}(' \rt. 1- STATE Li A ZIP a S('
<br /> OWNER PHONE: OWNER EMAIL: c�
<br /> nft 1,.`CR.... :. ..-r....:,N... — ..,..x. i....-.a. ..,...�k.....q e,. . ..,,.,. , .,,. .,.,_.:..... ..-r.. �...........»m,,..s,,,,A,,,A,.., ' . ..,... M..",.r ......`,,,,,.,,a:,,. .vi,, ...,,,.. ,._. ,m+,a.......,
<br /> CONTRACTOR NAME: 1=4i` 5 r✓P l&refit/J,,r;e_cttio..v_->
<br /> CONTRACTOR ADDRESS: STREET Pv i30k 13L ct i (,
<br /> CITY 'I f+a f i-� C f'e,P I STATE W ZIP C ed S L.
<br /> CONTRACTOR PHONE:427- ?O5 Stu CONTRACTOR EMAIL:lc1J; c'C fcS4S a 0e C O.1.. .. (a•'-t. V`ePA
<br /> CONTRACTOR LIC.#(REQUIRED) l�fc t,c c ,1 3 CITY OF EVERETT BUSINESS LIC.#(REQUIRED)- .. �� ,
<br /> PRIMARY CONTACT: ❑OWNER 1V9ONTRACTOR ❑OTHER(Please Specify)
<br /> CONTACT NAME: CONTACT PHONE: �L 5-' Zv 7.- 5- 7 c
<br /> Gi�` /4`iC. .) > CONTACT EMAIL: -bat) , c")C.? •eae,f 5,to Co"...et . (I'd✓`'l
<br /> AGREEMENT.I hereby certify that 1 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 State Contractors Law 18.27 RCW and 296.200 WAC. City of Everett Official Use Only
<br /> PERMIT#:
<br /> C.
<br /> ;�:,—.- _ -2 - « -20 7.( E /(x),2--D?),(
<br /> Owner/Authorized Agent Signature Date (Revised 1/11/2019) Page 1-Application
<br />
|