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. . . ECTRICAL PERMIT APPLPATION
<br /> CITY OF EVERETT PERMIT SERVICES
<br /> j 3200 CEDAR STREET,EVERETT,WA 98201
<br /> .,,
<br /> (P)425-257-8810 1 FAX 425-257-8857 1(E)everetteps@everettwagov I www everettwa.gov/permits
<br /> PROJECT SITE INFORMATION
<br /> CI17\4, ' (I
<br /> PROJECT ADDRESS: 1 .(- i .A.,:,iA t L., 4,...4, 0(
<br /> BUILDING AREA: _;`)- --/ sq ft
<br /> PROJECT TYPE: il NEW CONSTRUCTION El ADDITION El TENANT IMPROVMENT REMODEL
<br /> BUILDING USE: 0 SFR CI TOWNHOUSE El DUPLEX El ADU El MULTI-FAMILY-#OF UNITS: Di COMMERCIAL
<br /> ELECTRICAL APPLICATION INFORMATION & DESCRIPTION OF WORK
<br /> CONTRACT PRICE OF WORK:kl i ,2z:je),.,--s„ ASSOCIATED BUILDING PERMIT#(if applicable):
<br /> DESCRIBE SCOPE OF WORK: tit/1A-. (C.,,,\I c,..k,,,j r r„..ctf,l ,v- 1/:.,,,?,,,„,-,....:2i,:,,-:-(,--7,4„S' e p,444,....„--,;)
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<br /> vve ( il(,s2-4.4,..t., 14,,
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<br /> THIS INSTALLATION INCLUDES THE FOLLOWING SCOPE: (SELECT ALL THAT APPLY)
<br /> LINE VOLTAGE WORK? A NO E YES-Select Scope:El Service El Feeder E]Circuits-t Ill Complete Re-wire
<br /> LOW VOLTAGE WORK? El NO YES-#of Devices: (19
<br /> SELECT SCOPE(REQUIRED): [Ti Data CI Intercom EI Thermostat E Audio El 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 /> El Other(List All): _
<br /> CODE COMPLIANCE
<br /> IS THIS PERMIT EDUCATION,INSTITUTIONAL,HEALTH AND/OR PERSONAL CARE FACILITIES: rl NO El YES-See Below&Pg.2
<br /> N. By checking this box, I am stating that I have read and understand all of WAG 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:ONO 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-pr „,4 t,A,Z,,A7‘,1„A...., ..k^b5I, )I‘ 1,4'0,1c TENANT BUSINESS NAME(If Commercial):
<br /> OWNER MAILING ADDRESS: STREET
<br /> CITY STATE ?IP
<br /> OWNER PHONE: OWNER EMAIL:
<br /> CONTRACTOR NAME: C IL ( it,AII/).VIII AII,Il',.1
<br /> CONTRACTOR ADDRESS: STREET IC"31,d O, ,L,I<ifst Av<, <5 v.) ::::,,;,2\ ,,-- 2.)3 (..)
<br /> 47,---(,----;.---;
<br /> C11 Y iI.,4Z4v‘,./ti,',,\ STATE Ai\ ZIP i(I)k--I,-I /
<br /> CONTRACTOR PHONE:2..13(0- 1'.11 qt1, ) 5 CONTRACTOR EMAIL: r:t.4)L kilZ....,//3 ,.....9,,L.,po,A..,eq-1 I i 4 q,, L.-c,--"--
<br /> CONTRACTOR LIC.#(RECIIIIRED): CITY OF EVERETT BUSINESS LIC_#(REQUIRED): .—.
<br /> PRIMARY CONTACT: [DOWNER 'ECONTRACTOR nOTHER(Please Specify)_ _......._ ..
<br /> CONTACT NAME: CONTACT PHONE: 7_,(,)Co - -1"3 9. •4-1(.\;
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<br /> 1-12-;'',1--- K,L1,,z,,, CONTACT EMAIL i. t., I.- il.. , 43:7 (: r* -,pCITI,A-Iej '
<br /> AGREEMENT I hereby certify that I have read Jiff examined this application and know the same to be true and correct. All provisions of laws and ordinances governing ills
<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 slate or
<br /> local law regulating construction or the performance of construction, that lam authorized by the owner of this property to perlorm the work for which application is made and I
<br /> comply with the Stale Contractors Law 18 27 RCW and 296.200 WAG. City of Everett Official Use Only
<br /> Owner/Authorized Agent Signature Date (Revised 1/11/2019) Page i-Application
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