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<br /> 161 HIE ELECTRICAL PERMIT APPLICATION
<br /> CITY OF EVERETT PERMIT SERVICES
<br /> EVERETT 3200 CEDAR STREET,EVERETT,WA 98201
<br /> wAsoitorron ,
<br /> (Pi 4 2 5-2 5 7-8 10 i FAX 425-257-8857 I(E.)everetteps@everetiwa.gov i www.everettwa..gov/permits
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<br /> PROJECT ADDRESS: 2 1'2-'1 17..7_no( pu to EnfekrAit BUILDING AREA: sq ft
<br /> PROJECT TYPE: 0 NEW CONSTRUCTION 0 ADDITION 0 TENANT IMPROVMENT gIREMODEL
<br /> BUILDING USE: aSFR El TOWNHOUSE 0 DUPLEX 0 ADU 0 MULTI-FAMILY-#OF UNITS: El COMMERCIAL
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<br /> CONTRACT PRICE OF WORK:$ t Ctil 0 ASSOCIATED BUILDING PERMIT#(if applicable):
<br /> DESCRIBE SCOPE OF WORK: pa4A2A OtAwAab
<br /> THIS INSTALLATION INCLUDES THE FoupWING SCOPE: (SEV CT ALL THAT APPLY)
<br /> [2,1
<br /> LINE VOLTAGE WORK? NO n. El Feeder El Circuits#: El Complete Re-wire
<br /> LOW VOLTAGE WORK? NO El YES-#of Devices:
<br /> g YES-Select Scope: Service
<br /> SELECT SCOPE(REQUIRED): CI Data 0 Intercom 0 Thermostat 0 Audio El Secure Access EI 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 /> nallis',i:-,-' ,4‘\!.,7;'Si,,,,ii. 17.74,.41440.1011 , '„ij.„!lr:''t.44CVFEW V'':,...,,, .....ea' _W . *tZ.4Z-2iai#*
<br /> IS THIS PERMIT EDUCATION,INSTITUTIONAL,HEALTH AND/OR PERSONAL CARE FACILITIES: u NO U YES—See Below&Pg.2
<br /> ri 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: ENO EYES-See Below&Pg.3
<br /> — Pursuant to ROW 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 /> '1.i--,-. 46•64' ' 11 , .t,:',,,;5,1 ,,,, ::,,,,,,,,,r,:v.). K.1:,"IM.;
<br /> OWNER NAME:Ck\V kSt4001,V\1 Etct TENANT BUSINESS NAME(If Commercial):
<br /> OWNER MAILING ADDRESS: STREET '2.42:1 t2,2M p I, (i-G---
<br /> COY STATE\Alf 211AVOS
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<br /> OWNER PHONE: OWNER EMAIk °‘""----
<br /> CONTRACTOR NAME: 1/1 411>k,A -Fte--6-f-vt ti
<br /> CONTRACTOR ADDRESS: STREET t 3c;) I ri-i-V\ bY
<br /> CITY I lUa CrrieArellt- STATE (AI A z.pclq 2. 1ra
<br /> CONTRACTOR PHONE: .4101)32-03 CONTRACTOR EMAIL: isnpipervihTtc(. rn0...A k.
<br /> CONTRACTOR LIC.#(REQUiRED): Cikacn24}6"/ JCITY OF EVERETT BUSINESS L .#(REQUIRED) t(0 c
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<br /> PRIMARY CONTACT: EIOWNER CONTRACTOR 00THER(Please Specify)
<br /> CONTACT NAME: CONTACT PHONE:,e-i2,..6 3?.....0
<br /> ' -e/tCerLi CONTACT EMAIL: "i41\04-OritS(P.4 M CU t *C1/4- 1"*.--_,
<br /> AGREEMENT:I hereby certify that/hove read and examined this application and know the same to be rue and correct. rovisions of laws and ordinances governing this
<br /> type of work t a 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
<br /> local law gulat g 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!
<br /> comply th the tate Co rectors Law 18.27 Row and 298.200 WAC. City of Everett Official Use Only
<br /> PERMIT#:
<br /> 12--1 /I q
<br /> 1 . E \ q \ c2-,— ) 16'6
<br /> Owner/ ut r zed Ag nt Signa re Da (Revised 1111/2019) Page I-Application
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