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<br /> ELECTRICAL PERMIT APPLICATION
<br /> CITY OF EVERETT PERMIT SERVICES
<br /> EVERETT 3200 CEDAR STREET,EVERETT,WA 8E1201
<br /> (P)425-257-8t110 I FAX 42;"5•25?-8B5/ 11E)ovorotteps@evorottwagov I www.cvumawd.govipurrults
<br /> W14 5 HIP,:C:7C1 t,/
<br /> PROJECT SITE INFORMATFON -
<br /> PROJECT ADDRESS: lk,i -13)"'.6* 6,,,A) SUILDING AREAi sq ft
<br /> PROJECT TYPE: LI NEW CONSTRUCTION LI ADDITION CA TENANT IMPROVMENT El REMODEL
<br /> BUILDING USE: LK)SFR El TOWNHOUSE El DUPLEX til ADU 0 MULTI-FAMILY-ft OF UNITS: El COMMERCIAL
<br /> ELEdTRICA , .:,A:4' , - : 0 : 0100010N &DESCNIPTION,OV<VVOIRK-qllt:C'
<br /> •CONTRACT PRICE OF WORK:$ WO ASSOCIATED BUILDING PERMIT#(if applicable):
<br /> I DESCRIBE SCOPE OF WORK: Ulif-t aika r4144 Fttrviaa Isiame, .....,
<br /> THIS INSTALLATION INCLUDES THE FOLLOWING SCOPE; ALL THAT AP, Y)
<br /> pt.'"
<br /> LINE VOLTAGE WORK? El NO 0 YES-Sol S pe:0 Service 0 Fee r7)Circii64/: 1 CI Complete Re-wire
<br /> KV,
<br /> LOW VOLTAGE WORK? LI NO ro° YES.# f D vices: ) _
<br /> SELECT SCOPE(REQUIRED): El Data LI Intercom [ Thermostat El Audio El Semite AOCe El Security System
<br /> El Fire Alarm-Installatio under this per ' only include e1eticI wiring r h-In of the System.Ati additional
<br /> Fire Alarm Permit is reiuIreforevIew device location and installation approval.
<br /> 0 Other(List All):
<br /> ..--- . , .....„„.. ....... ..,...._„._ ... . —
<br /> CODE COMPLIANCE
<br /> IS THIS PERMIT EDUCATION,INSTITUTIONAL,HEALTH AND/OR PERSONAL CARE FACILITIES: P NC) 0 YES—See Below&Pg.2
<br /> F---1 By checking this box,I am stating that I have road and understand all of INAC 206,0M-000,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 sal)sections ihat do not
<br /> See Pap 2 require Plan Review.
<br /> ARE YOU AN OWNER PERFORMING WORK AS THE CONTRACTOR WITHOUT ELECTRICAL LICENSURE: NO EYES-See Below&Pg.3
<br /> Fl Pursuant to RCW IS.28_261,properly 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 chocking this box,I am stating that I have completed and
<br /> See pap 3 signed the AFFIDAVIT on page 3 of this application to receive an exemption from this licensingicertificati on requirement.
<br /> CONTACT INFORMATION '' ' -' '
<br /> _ — —,
<br /> OWNER NAME:Nor YI aril C-14)MCS, TENANT BUSINESS NAME(if Commercial):
<br /> OWNER MAILING ADDRESS: STREET 1.04 Tbrd CS+ EVU
<br /> cm, eVaar ,,;A 16 ‘Ij tti' ii.q fYIL$ ,
<br /> OWNER PHONE:kitt i ?Ale, b01-1A-I OWNER EMAIL: ihl 440,9 igiut.riaelett corn Fort.cowl
<br /> CONTRACTOR NAME: NUL fiaffiAl, klUallil t, tiv
<br /> CONTRACTOR ADDRESS: 3TREET 11%th4 1,1,0441 St SIA) 'lilt
<br /> cll., 1,4AM'*lakt Terragt STATE LA•iii ZP 1 tt 6 LA:1,i
<br /> CONTRACTOR PHONE: 1,4 Tr".lit-itS1 CONTRACTOR EMAIL: vrif0.0 k,otui -r-iiwri&c.vivItr-alf-i-,cevii
<br /> CONTRACTOR LIC.#(REQUIRED):1?ws-r-if:+i.s 1.--Ipv CITY OF EVERE t I BUSINESS LIC.#(REOUIRED): to 04 36
<br /> PRIMARY CONTACT: Ir.otWNER LCONTRACTOR []OTHER(PleaSe Specify)
<br /> -CONTACT NAME: CONTACT PHONE: 141h. 1).1406 . 5001,Li
<br /> 1 136y-raid 618 ma '
<br /> CONTACT EMAIL: wiftt 0 Iv:Ada-Amu coneihri-,4,4w)
<br /> AGREEMENT-I hereby certify that/have read end exarriiriod tits twilikafilen told Mow the same to be true&Yid cQrract All proVisions of taw.and ordinances governing this
<br /> type of work mg be aompleteri whether*peeled herein or out the granting la it permit does not presume to owe ouffionty to dotste or cencet the provisions of any other state or
<br /> tocet taw regMeting conathinhon ar the prolormarico of oonstneution. That t am authorized by the owner of this property to perform the work for which application is made and I
<br /> conlniy ebb the State Contrechws taw f a Pi ACV/and 296200 WA C City of Everett Officiel Use only
<br /> PERMIT#:
<br /> ______
<br /> 1
<br /> :1 -;°4 -- E RoR — 1 0
<br /> OwnedAut xed Agent Signature Date (Rovrsed 1/./112019) Page 1-Applitierr
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