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ELECTRICAL PERMIT APPLICATION
<br /> EVERETT 32 CITY OF EVERETT PERMIT SERVICES
<br /> 00 CEDAR STREET,EVERETT,WA 98201
<br /> WASHINGTON (P)425-257-8810 I FAX 425-257-8857 I(E)everetteps@everettwa.gov I www.everettwa.gov/permits
<br /> PROJECT,SITE'INFORMATIO
<br /> PROJECT ADDRESS: f `; ` i 3 Ki4. 1 .r ,4 BUILDING AREA: sq ft
<br /> PROJECT TYPE: ❑ NEW CONSTRUCTION ❑ADDITION ❑TENANT IMPROVMENT [XREMODEL
<br /> BUILDING USE: ❑SFR El TOWNHOUSE ❑ DUPLEX Cl ADU ❑ MULTI-FAMILY-#OF UNITS: %COMMERCIAL
<br /> ELECTRICAL APPLICATION INFORMATION S'DESCRIPTION OF WORK
<br /> CONTRACT PRICE OF WORK:$ M 2,7 c v ASSOCIATED BUILDING PERMIT#(if applicable):
<br /> DESCRIBE SCOPE OF WORK: 6A-e e-- (6) 0.0- at/ Mats, Li)l r )11,V LS
<br /> LE 6 ;,AL lv...la.r1, 5 c'F-F. ./- s /, t---is (6
<br /> THIS INSTALLATION INCLUDES THE FOLLOWING SCOPE: (SELECT ALL THAT APPLY)
<br /> LINE VOLTAGE WORK? ❑ NO YES-Select Scope: ❑ Service CIFeeder El Circuits-#: CIComplete Re-wire
<br /> LOW VOLTAGE WORK? 0.NO ❑YES-#of Devices:
<br /> SELECT SCOPE(REQUIRED): ❑ Data ❑ Intercom ❑ Thermostat ❑Audio ❑Secure Access ❑Security System
<br /> ❑ 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 /> ,CODE:;COMPLIANCE
<br /> IS THIS PERMIT EDUCATION, INSTITUTIONAL, HEALTH AND/OR PERSONAL CARE FACILITIES: ,N NO El 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 LICENSURENO EYES-See Below&Pg. 3
<br /> 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 /> OWNER NAME: cJ�%' �, ,� l C_ TENANT BUSINESS NAME(If Commercial): E.i ei•t`ef-1- (.mil ; , L
<br /> OWNER MAILING ADDRESS: STREET
<br /> CITY STATE ZIP
<br /> OWNER PHONE: OWNER EMAIL:
<br /> CONTRACTOR NAME: 61511
<br /> CONTRACTOR ADDRESS: STREET '1 '1 I -1 7' jP. riL`
<br /> CITY /NI G‘-ry S v J fie_ STATE (,,,J; ZIP 9&1"7C
<br /> CONTRACTOR PHONE: Lf LS ) ,p 671y7 CONTRACTOR EMAIL: {�'✓tsl'.e-i+ i- ic, 1/(--(l/�`` / ( w1
<br /> CONTRACTOR LIC.#(REQUIRED) 1 j6L1^L g I . 1)`L CITY OF EVERETT BUSINESS LIC #(REQ ED) (g...)47 yy
<br /> ...��._. ,_,... _ .....�.�.a�� �•,�� �, .,,,....F__,.�<.. �,. ."M,.ti ,�.v.�....,--,_ ,_. . �.,,a�. .,e,�....,o....-Map..� . e � �..
<br /> PRIMARY CONTACT: ❑OWNER ONTRACTOR ❑OTHER(Please Specify)
<br /> CONTACT NAME: ti CONTACT PHONE: 1.1 7 S 7 ) 7
<br /> It c (l\ r/ C, ,;- c-c-(, CONTACT EMAIL: rvk Ft�IEv4f C. iC . in/.0.4I I. a \
<br /> AGREEMENT.:I hereby certify that I have read and examined this application and know the same to be true and correct. All provisions laws ( ry
<br /> 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!am authorized by the owner of this property to perform the work for which application is made and!
<br /> comply with the State Contractors Law 18.27 RCW and 296.200 WAC. City of Everett Official Use Only
<br /> PERMIT#:
<br /> - Z
<br /> Owne4/Authorized Agent Signature Date (Revised 1/11/2019) Page 1-Application
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