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A 10 0 ELECTRICAL PERMIT APPLICATI01 EVERETT WASHINGTON CITY OF EVERETT PERMIT SERVICES 3200 CEDAR STREET, EVERETT, WA 98201 (P) 425-257-8810 1 FAX 425-257-8857 1 (E) everetteps@everettwa.gov I www,everettwa.gov/permits PROJECT SITE INFORMATION PROJECT ADDRESS: BUILDING AREA: sq ft PROJECT TYPE: ❑ NEW CONSTRUCTION ❑ ADDITION ❑ TENANT IMPROVMENT JKEMODEL BUILDING USE: SFR ❑ TOWNHOUSE ❑ DUPLEX ❑ ADU ❑ MULTI -FAMILY - # OF UNITS: ❑ COMMERCIAL ELECTRICAL APPLICATION INFORMATION & DESCRIPTION'OF WORK CONTRACT PRICE OF WORK: $ n DL ASSOCIATED BUILDING PERMIT # (if applicable): DESCRIBE SCOPE OF WORK: v F THIS INSTALLATION INCLUDES THE FOLLOWING SCOPE: (SELECT ALL THAT APPLY) LINE VOLTAGE WORK? ❑ NO ZYES - Select Scope: ❑ Service ❑ Feeder ❑ Circuits-#: omplete Re -wire LOW VOLTAGE WORK? ❑ NO ['YES- # of Devices: SELECT SCOPE (REQUIRED): ❑ Data ❑ Intercom ❑ Thermostat ❑ Audio ❑ 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 El 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 -]YES -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 X-V Seeage 3 signed the AFFIDAVIT on page 3 of this application to receive an exemption from this licensing/certification requirement. CONTACT I NFORMATION ._ OWNER NAME: TENANT BUSINESS NAME (If Commercial): 77 OWNER MAILING ADDRESS: STREET A /a CITY"J' STATE 21P OWNER PHONE: tf ' �• 1OWNEIR EMAIL: CONTRACTOR NAME: CONTRACTOR ADDRESS: STREET ` CITY STATE- ZIP l' CONTRACTOR PHONE: /L_ /J�" 7 ONTRACTOR EMAIL: 5 yc{� PY) r>~ - J j n l ,y ,� ✓"�' _,, %,ram CONTRACTOR LIC. #(REQUIRED): OF EVERETT BUSINESS LIC. #(REQUIRED): PRIMARY CONTACT: ❑OWNER CONTRACTOR ❑OTHER (Please Specify) CONTACT NAME: t CONTACT PHONE: L� j� Q 5L`� % CONTACT EMAIL: ! , AGREEMENT:/ hereby certify that/ have read and examined this application and know the same to be true and correct. All 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/ 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 #: E'i�I'I� (Revised 1/1112019) Page 1-Application