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® • • ELECTRICAL PERMIT APPLICATION EVERETT 32 CITY OF EVERETT PERMIT SERVICES 00 CEDAR STREET,EVERETT,WA 98201 WASHINGTON (P)425-257-8810 FAX425-257-8857 I(E)everetteps@everettwa.gov www.everettwa.gov/permits PROJECT SITE INFORMATION PROJECT ADDRESS: /!fin'J j PJ J fit, BUILDING AREA: sq ft PROJECT TYPE: ❑ NEW CONSTRUCTION ❑ADDITION ❑TENANT IMPROVMENT V REMODEL BUILDING USE: IX SFR ❑TOWNHOUSE ❑ DUPLEX ❑ADU ❑ MULTI-FAMILY-#OF UNITS: —1 COMMERCIAL ELECTRICAL APPLICATION INFORMATION & DESCRIPTION OF WORK CONTRACT PRICE OF WORK:$ b: .i ASSOCIATED BUILDING PERMIT#(if applicable): DESCRIBE SCOPE OF WORK: D(,i)JIB) /\b(4,; (—)J 17 )74I G'r) CkC.JL--' ` ;l✓ THIS INSTALLATION INCLUDES THE FOLLOWING SCOPE: (SELECT ALL THAT APPLY) LINE VOLTAGE WORK? ` ,NO ❑YES-Select Scope: ❑ Service ❑ Feeder ❑ Circuits-#: ❑ Complete Re-wire LOW VOLTAGE WORK? ❑ NO ❑YES-#of Devices: SELECT SCOPE(REQUIRED): ❑ Data ❑ Intercom E Thermostat ❑Audio El Secure Access ❑ Security System ❑ 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 device location and installation approval. ❑ Other(List All): 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: ❑NO RYES-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: Liw I u Ko\-1)0 TENANT BUSINESS NAME(If Commercial): OWNER MAILING ADDRESS: STREET /0 F_) 19 C CITY J`l It lI}j5b STATE `v`.' `1 ZIP C/�I UZ OWNER PHONE LI F)0--(p0,26u.f. OWNER EMAIL j KC-11)O f() LI I i (.1w CONTRACTOR NAME: CONTRACTOR ADDRESS: STREET CITY STATE ZIP CONTRACTOR PHONE: CONTRACTOR EMAIL: CONTRACTOR LIC.#(REQUIRED): CITY OF EVERETT BUSINESS LIC.#(REQUIRED): PRIMARY CONTACT: OWNER ❑CONTRACTOR ['OTHER(Please Specify) CONTACT NAME: CONTACT PHONE: L` _ S)O - c ( l,c.Uk \(/\N y- CONTACT EMAIL: 1`La1CCt l G cj fl— J 1 c It AGREEMENT:I hereby certify that I have read and examined this application and know the same to be true and correct: II 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 Contractors Law 18.27 RCW and 296.200 WAC. City of Everett Official Use Only PERMIT#: ` i 1 170E:D I-ct-4? /Owier/Authorized Agent Signature Date (Revised 1/11/2019) Page 1-Application