Laserfiche WebLink
0 i <br /> OLT ELECTRICAL PERMIT APPLICATION <br /> CITY OF EVERETT PERMIT SERVICES <br /> 3200 CEDAR STREET,EVERETT,WA 98201 <br /> (P)425-257-8810 I FAX 425-257-8857 I(E)everetteps@everettwa.gov I www.everettwa.gov/permits <br /> PROJECT SITE INFORMATION <br /> PROJECT ADDRESS:\\(QR\) IJ\r* 2_1�k • BUILDING AREA: sq ft <br /> PROJECT TYPE: ii NEW CONSTRUCTION ADDITION 0 TENANT IMPROVMENT 0 REMODEL <br /> BUILDING USE: ❑SFR 0 TOWNHOUSE ❑DUPLEX 0 ADU 0 MULTI-FAMILY-#OF UNITS: 11 COMMERCIAL <br /> ELECTRICAL APPLICATION INFORMATION.& DESCRIPTION OF WORK . . <br /> CONTRACT PRICE OF WORK:$ (,. ) `— ASSOCIATED BUILDING PERMIT#(if applicable): <br /> DESCRIBE SCOPE OF WORK: ••\ C) C) �- /V -- Yl i L1C�Aidle t�� ��`(1 �- <br /> J J <br /> THIS INSTALLATION INCLUDES THE FOLLOWING SCOPE: (SELECT ALL THAT APPLY) <br /> LINE VOLTAGE WORK? ❑NO ❑YES-Select Scope: 0 Service ❑Feeder ❑Circuits-#: ❑Complete Re-wire <br /> LOW VOLTAGE WORK? 0 NO YES-#of Devices: i "r <br /> SELECT SCOPE(REQUIRED): 0 Data ❑Intercom ❑Thermostat 0 Audio 0 Secure Access ❑Security System <br /> ti 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 /> 0 Other(List All): <br /> • _CODE COMPLIANCE <br /> IS THIS PERMIT EDUCATION,INSTITUTIONAL,HEALTH AND/OR PERSONAL CARE FACILITIES: \NO 0 YES--See Below&Pg.2 <br /> 0 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: E1 N0 DYES-See Below&Pg.3 <br /> 0 Pursuant to RCW 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 /> CONTACT.INFORMATION . ; <br /> OWNER NAME: TENANT BUSINESS NAME(If Commercial) ()\Th '- CA 111_15\( , <br /> OWNER MAILING ADDRESS: STREET ..1225 \rc)V-- A:U• _ <br /> CITY .A.Qi STATE ,\v'\ ZIP ; ; . <br /> OWNER PHONE: ,'1 - ��7 C\ !OWNER EMAIL: <br /> we-,\ `C� <br /> CONTRACTOR NAME: .A,\� r( \i[—VC\ il- 'c)L;aY� ^ a . <br /> CONTRACTOR ADDRESS: STREET \\'k2' \k '4\ . <br /> CITY ti` `JZ STATE \NJ.: yZIP `✓� [�C4 <br /> "` '^ j��// CONTRACTOR EMAIL. `''.\cC y,KlV\,G\\CAN.C\^R�zQ VVY'a `CA-2A`c <br /> CONTRACTOR PHONE:tt' VC% '' H � �� i� <br /> CONTRACTOR LIC.#(REQUIRED):C\\Q ) ? L.� CITY OF EVERETT BUSINESS LIC.#(REQUIRED):C-i3 'C"- <br /> PRIMARY CONTACT: ❑OWNER CONTRACTOR 0 OTHER(Please Specify) <br /> CONTACT NAME: CONTACT PHONE: WO UQ`1q,--9)- - Q <br /> R CONTACT EMAIL:ri. Nc-tAkiW 1,r\ (V1CVA'-Ca "'&Iavt• \"c.. <br /> AGREEMENT:I hereby certify t at 1 ha a read and examined this application and know the same)o be/rue and correct. All provisions of laws and ordinances governing this <br /> 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 <br /> local law regulating construction or the performance of construction. That I am authorized by the owner of this property to perform the work <br /> City for <br /> Everett applOffiication <br /> l n is made U s Only and I <br /> comply with the State Contractors Law 18.27 RCW and 296.200 WAC. <br /> PERMIT#: <br /> e- } <br /> Owner/Au horizedent S nature Date <br /> g 11V21 E ��ol - 2oC� <br /> �t' � C t tea' (Revised 1/11/2019) Page 1-Application <br /> � <br />