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'IR iiiis gm ELECTRICAL. PERMIT APPLICATION E V E R E T CITY OF EVERETT PERMIT SERVICES (P)425 257 8 3200 CEDAR STREET.EVERETT.WA 98201 WASHINGTCN 810 FAX 4e5-257-8857 i(E)everetteps@2vereftwa.gov f "rtiv.everetriva.gov/permits PROJECT SITE INFORMATION PROJECT ACDRESS: il -cO 't j 11.1. S:'i- BUILDING AREA: _so ft PROJECT TYPE: ❑ NEW CONSTRUCTION ❑ADDITION ,gi TENANT IMPROVMENT ❑REMODEL BUILDING USE: ❑SFR ❑TOWNHOUSE Ii DUPLEX ❑ADU ❑ MULTI-FAMILY-#OF UNiTS: COMMERCIAL ELECTRICAL CTRICAL APPLICATION INFORMATION & DESCRIPTION OF WORK CONTRACT PRICE OF WORK:$ 2_S cc,, 'ASSOCIATED BUILDING PERMIT#(if apblicable): DESCRIBE oCOPE OF WORK: 1,t3 - $T ___ 1 ram. ��.> •`n c Gc�Urc� r7crl�/� iz% I)i L-1 / THiS INSTAI-LATION INCLUDES ThE FOLLOWING SCOPE: (SELECT ALL THAT APPLY)LINE VOLTAGE WORK? CIfJO EYES-Select Scope: ElServ'ice ❑ Feeder ❑Circuits-#: LI rr; Complettt Re-wire LOW VOLTAGE WORK? KNo ❑YES-#of Devices: SELECT SCOPE(REQUIRED): ❑ E)ata ❑ Intercom ❑Thermostat ❑Audio ❑ Secure Access ❑ Security System ❑ Fire Alarm-Installations under this permit only include electrical wiring rough-in of the system.An additional Fire Alarm Permit is required for review of device location and installation approval. ❑Other(List Ail): ~--, CODE COMPLIANCE IS THIS PERMIT EDUCATION,INSTITUTIONAL,HEALTH AND/OR PERSONAL-CARE FACILI 'IES: 1111 NO RIYES-See Below&Pg. 2 — L3y checking this box, I am stating that i have read and Understand tall of WAC 296-46B-900, selected the specifi reason on page 2 pf this application(see nekt page),AND Plan Review is NOT required because I meet all of the following sub' ;ions that do not See Page 2 require Plan Review. ARE YOU AN OWNER PERFORMING Wt)RK AS THE CONTRACTOR WITHOUT ELECTRICAL LICENSURE: ENO ❑I',.:S-See Below&Pg. 3 •"-'-' Pursuant to RCW 19.28.261. property owners and leaseholders cannot perform electrical work on buildings for rent; sale,or lease vithout the proper electrical licensing arid certification,or exemption.By checking this box, I am stating that I have completed and See Page 3 pigned the AFFIDAVIT on rage 3 of this application to receive on exemption from this licensing/certification requirement. CONTACT INFORMATION ' 'OWNER NAMg: ?r+='.,-at_•`c�- L i(:i-t e.( l4k4.0.:1 TENANT BUSINESS NAME(If Commerchil): OWNER MAILING ADDREESS: STREET (EiC ( 6j..,,pi. A t)r- S '-jo/ CITY Qt'l1'O 1 STATE L4, zip eiet:, -+ OWNER PHONE: OWNER EMAIL: 'CONTRACTOR NAME: -'tLi-t tf,-(--t • t cj,-' le`ititc,ice,; c=> C._C- C_. CONTRACTOR,ADDRESS: STREET S�ltG�6 i/r( ?T4' j�;.`" y� G/� CITY fl IC_ [! STATE v;7Z' ZIP r0 -t' CONTRACTOR PHONE: '.3 - 2-Cti CONTRACTOR EMAIL: CONTRACTOR LIC,#(REQUIRED): V r-Cr4 E4 T ,Lt C Lt CITY OF EVERETT BUSINESS LIC.#(REQUIRED): CC'IL?54 S PRIMARY CONTACT: DOWNER ❑CONTRACTOR 40THER(Please Specify) i-i cic t/ite..'/ /ort....-.«z1 CONTACT NAME: CONTACT PHONE: >r�r1_ ,� CONTACT EMAIL: ' _ . '')'t ;��iecila ,.L(t r 'i'(:r'1. � j ?L-flrf t� '' b C=4'+.-,(-'I 4,`ds�tz� AGREEMENT:I hereby certify that i have read and examined this application and know the same to be true and correct. All provision cf laws and ordinances governing this 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 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 t comply with the State Contractors Law 18.27 RCW and 296.200 WAC. City of Everett Official Use Only dPERMIT#: nerlAuthorize A ant Signature Date (Revised 1/11/2019) Page'I-Application