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NM
<br /> LI OECTRICAL PERMIT APPLIOATION
<br /> CITY OF EVERETT PERMIT SERVICES
<br /> EVERETT 3200 CEDAR STREET, EVERETT,WA 98201
<br /> WASHINGTON (P)425-257-8810 I FAX 425-257-8857 I(E)everetteps@eyerettwagoy I www.eyerettvra goy/permits
<br /> PROJECT SITE INFORMATION
<br /> ,....
<br /> PROJECT ADDRESS: 3:50 1 7 l'-t-t---1--( . --1--- -4-)t.._ BUILDING AREA: sq ft
<br /> PROJECT TYPE: E NEW CONSTRUCTION El ADDITION TENANT IMPROVMENT D REMODEL
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<br /> BUILDING USE: Ifs'S-F-R 7 TOWNHOUSE El DUPLEX 1:1-ADLJ CI MULTI-FAMILY-#OF UNITS: 7 COMMERCIAL
<br /> ELECTRICAL APPLICATION INFORMATION & DESCRIPTION OF WORK
<br /> CONTRACT PRICE OF WORK: $ \1::: iC.:) ASSOCIATED BUILDING PERMIT#(if applicable):
<br /> DESCRIBE SCOPE OF WORK: \rA,..( e— Vc- .QV
<br /> .A...cx -z--*- \----- ...,--' e, Y...., ..-9.--
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<br /> THIS INSTALLATION INCLUDES THE FOLLOWING SCOPE: (SELECT ALL THAT APPLY)
<br /> LINE VOLTAGE WORK? 0 NO 0 YES-Select Scope:& rvice Cil Feeder El Circuits-#; 0 Complete Re-wire
<br /> -,...._
<br /> LOW VOLTAGE WORK? El] NO E1 YES-#of Devices:
<br /> SELECT SCOPE(REQUIRED): E Data 7 Intercom 7 Thermostat 7 Audio El Secure Access 7 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 /> 7 Other(List All):
<br /> CODE COMPLIANCE
<br /> IS THIS PERMIT EDUCATION, INSTITUTIONAL, HEALTH AND/OR PERSONAL CARE FACILITIES: fl NO LI 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: 4 NO EYES-See Below& Pg. 3
<br /> Pursuant to RCW 19.28.261, property owners and leaseholders cannot perform electrical work on buildi .s 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: rNA:)/ ,f.) )('''Cx.:1:: 7"-Ns' TENANT BUSINESS NAME(If Commercial):
<br /> OWNER MAILING ADDRESS: STREET -.3(..)
<br /> CM' ..-\)cj,-. .,-..„. STATE „)\,, IL,..,_ LP Ct yci‘L
<br /> OWNER PHONE:L/'‘7 '" ?'3 —P7 1 l_ck OWNER EMAIL:
<br /> CONTRACTOR NAME: \IV- \ k'-' \\10-1\--e---? t:::.--1, 'e1:.* C- t....:\--C_
<br /> CONTRACTOR ADDRESS: STREE- 74-7.(3 ' —'. --)--.. .V-- a_ , s
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<br /> \, ) A \f.., SATE ‘,./k, .A., ..,. TP-9-4g..),..03
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<br /> CONTRACTOR PHONE: 471a5"-: '...7F(& CONTRACTOR EMAIL: .-t Ve.v.,,N. NOCk6;-' Cfr'..spt„..,t N..., C..- ."0..
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<br /> CONTRACTOR LIC.#(REQUIRED), .,'': \KTI-V-...t.)1EL.. "3‘ k,e,siClTY OF EVERETT BUSINESS LIC.#(REUIRED): 'C.; r"7. '3 .)
<br /> PRIMARY CONTACT: EDOVVNER tit 0 ' RACTOR DOTHER(Please Specify)
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<br /> CONTACT NAME: CONTACT PHONE: L47C:77. - --
<br /> 70 k
<br /> re- LCL--- CONTACT EMAIL:
<br /> AGREeMENT.I hereby certify that I have read and examined this application and know the same to be true and correct Al!provisions of laYPs and ordinances governing this
<br /> type of work will be completed whether specified herein or not. The granting of a pertntt 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 I am authonzed 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.
<br /> City of Everett Official Use Only
<br /> ,72 PERMIT#:
<br /> i----1*--- V.-1 5/1 E K7 I I - 015
<br /> ner/Authori ent Si re ate (Revised 111112019) Page 1-Application
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