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R <br /> ECTRICAL PERMIT APPLOATION <br /> EVERETT art OFEVERETTPEg2twrSF�ICES <br /> az09 BAR S•rr E r,EVEREFf,WA982131 <br /> WASHlNGTON (P)425-257-8810 I FAX 425-257-8857 }IE)evereiteps@everattwa,gaov wever govipem its <br /> PROJECT'SITE INFORMATION <br /> PROJECT ADDRESS: 3 6.z s$ / ?c•'a e%ez,/ !BUILDINGAREA: sq ft <br /> PROJECT TYPE: 0 NEW CONSTRUCTION ❑ADDITION s tNANT IMPROVMENT 0 REMODEL <br /> BUILDING USE: ❑SFR t—:l TOWNHOUSE ❑DUPLEX ❑ADU CI MULTI-FAMILY-#OF UNITS: 'r'��RRCiAL <br /> ELECTRICAL APPLICATION INFORMATION & DESCRIPTION OF WORK <br /> CONTRACT PRICE OF WORK:$ 2, 50d .ASSOCIATED BUILDING PERMIT#(if applicable): <br /> DESCRIBE SCOPE OF WORK: "..e/o c-c / [� �C�S f j .-l5 ,' r4 - ," /57,, -y—e/' Oc.r.,‘,// <br /> Pal 7i- <br /> THIS INSTALLATION INCLUDES THE FOLLOWING SCOPE: (SELECT ALL THAT APPLY) <br /> LINE VOLTAGE WORK? El NO RYES-Select.Scope: ❑Service ❑ Feeder ❑ Circuits-#: ❑Complete Re-wire <br /> LOW VOLTAGE WORK? ❑NO ®YES-#of Devices: <br /> SELECT SCOPE(REQUIRED): ❑ Data -gElfitexcom ❑Thermostat El-Audio El Secure Access ❑ 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 /> ❑ Other(List All): <br /> CODE COMPLIANCE <br /> IS THIS PERMIT EDUCATION, INSTITUTIONAL, HEALTH AND/OR PERSONAL CARE FACILITIES: 7-NO ❑YES--See Below&Pg.2 <br /> I By checking this box,1 am stating that 1 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 /> 1 1 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 INFOSIMATION <br /> i 1 -- _ <br /> OWNER NAME: TENANT BUSINESS NAME(If Commercial): <br /> S�Gr/G1G•C'Iz <br /> ,, <br /> OWNER MAILING ADDRESS: STREET <br /> COY STATE TiP <br /> OWNER PHONE: OWNER EMAIL..: <br /> CONTRACTOR NAME ! 5/7�.r L-S .S/5i1 02 Li,'9/ / <br /> CONTRACTOR ADDRESS: smEEr p S/S ���T��/✓ <SG' �j�/7 <br /> �crrrs// "/P7/ 'S STATE 1-4--7Yq BP 7Y-2/!1 <br /> CONTRACTOR PHONE7.,�.-J�S-'Uo/k CONTRACTOR EMAIL: /'Yi 7'2 S <br /> CONTRACTOR LIC:#(REQUIRED): I d LTR S L g$I 0-7 CITY OF EVERETT BUSINESS LAC.#(REQUIRED): Fj']_g 3 Z <br /> PRIMARY CONTACT: DOWNER TRACTOR ❑OTHER(Please Specify) <br /> CONTACT NAME: CONTACT PHONE: 1:4 s' -l/6/‘ <br /> I e't: et;//- $ CONTACT EMAIL: /jG/-4,5 <br /> AGREEMENT::1 hereby certify that I have read and examined this application and know the same to be true 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 for which application is made and I <br /> scorrlplywvith the State Contractors Law 1:6.27 ROW and 296.200'WAG. City of EVerstt Official Use-Only <br /> PERMIT#: <br /> E Ito - 11 4-- <br /> Owner/Autho ed Agent Signature Date (Revised 1J11/2019) Page 1-Application <br />