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� ELECTRICAL PERMIT APPLICATION <br />EVERETT 32CITY OF EVERETT PERMIT SERVICES <br />00 CEDAR STREET, EVERETT, WA 98201 <br />WASHINGTON (P) 425-257-8810 1 FAX 425-257-8857 1 (E) everetteps@everetlwa.gov I www.everettwa.gov/permits <br />P!tp,113OT. l <br />TRINIFORMXT . . <br />PROJECT ADDRESS: 1a rbocost Dir.BUILDING AREA: SI (X sq ft <br />PROJECT TYPE: ❑ NEW CONSTRUCTION ❑ ADDITION NfTENANT IMPROVMENT ❑ REMODEL <br />BUILDING USE: ❑ SFR ❑ TOWNHOUSE ❑ DUPLEX ❑ ADU ❑ MULTI -FAMILY - # OF UNITS: ❑ COMMERCIAL <br />ELECTRICAL: APPLICATION :INF,O <br />iMATIONA DR$�C�ItIPTj0N`,0 W0R <br />CONTRACT PRICE OF WORK: $ 6`rD <br />ASSOCIATED BUILDING PERMIT # (if applicable): . <br />DESCRIBE SCOPE OF WORK: C t yc r S r 7r� C i—I'G t irCi-t, o 4_ ZtX_) A P/1-io tS-a- <br />( ►l e- (� • le'MC-' Z00 " O 11 mt N g /Q- ,- <br />L L. /o / 2 (' ONNErr­- Att LOLCLI f <br />THIS INSTALLATION INCLUDES THE FOLLOWING SCOPE: (SELECT ALL THAT APPLY) <br />LINE VOLTAGE WORK? ❑ NO © YES - Select Scope: S Service ® Feeder ® Circuits-#: (•I ❑ Complete Re -wire <br />LOW VOLTAGE WORK? ® 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 />❑ Other (List All): <br />taQDE,+ lIAR41 <br />IS THIS PERMIT EDUCATION, INSTITUTIONAL, HEALTH AND/OR PERSONAL CARE FACILITIES: NNO Ll YES-- See Below & Pg. 2 <br />❑ By checking this box, I am stating that I have read and understand all of WAC 29646B-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: ❑NO YES -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/applications to receive an exemption from this licensing/certification requirement. <br />I NJ SORT W.�.: <br />OWNER NAME: (Xtrf_ ,ore'S Luz �k;e,}r� Cctm KU TENANT BUSINESS NAME if Commercial): fj1A <br />OWNER MAILING ADDRESS: STREET 21 S tvt fi J <br />f <br />CITY `�.t i_ rt STATE L J A zip �/, 2 0 <br />OWNER PHONE: ►-k2:1 - U_-7,4 LS <br />OWNER EMAIL: bL L3,A <br />CONTRACTOR NAME: F-LtV.) SP0VCCr_ <br />CONTRACTOR ADDRESS: STREET u W P Vl tLt t <br />^ <br />CITY e�e. STATE zip L G7 <br />CONTRACTOR PHONE: U 11 `) .? ti Z <br />CONTRACTOR EMAIL: t� v>1e c=tk 1rC � a 'LjAlt, C c�YYt <br />CONTRACTOR LIC. #(REQUIRED): Idr4 LlC; . <br />CITY OF EVERETT BUSINESS LIC. #(REQUIRED): tJ A <br />PRIMARY CONTACT: DOWNER XCONTRACTOR ❑OTHER (Please Specify) <br />CONTACT NAME: <br />�7 Jh ` eon v cc_r✓_ <br />CONTACT PHONE: 2-0 C (Ic( <br />CONTACT EMAIL: LO.tie_ C[Ae_( <br />AGREEMENT: I hereby certify that 1 have reaa anti examines this apptcauon and know me same io oe uue anu correct. rm pruw runs tit 1aw4 anu wumancca yuraria„y <br />type of work will be completed whether specked 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 />comply with the State Contractors Law 18.27 RCW and 296.200 WAC. City of Everett Official Use Only <br />PERMIT M. <br />wit / C',� E <br />Owner/Authorized Agent Signature ,N j�j //Date (Rev/sad 1/1112019) Page 1-Application <br />