Laserfiche WebLink
110 • <br /> erm <br /> • ` 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 INFORMATION <br /> PROJECT ADDRESS: �� iK��( . vit. BUILDING AREA: 1IC)Q sq ft <br /> PROJECT TYPE: ❑ NEW CONSTRUCTION ❑ADDITION aTENANT IMPROVMENT ❑ REMODEL <br /> BUILDING USE: SFR El TOWNHOUSE ❑ DUPLEX ❑ADU ❑ MULTI-FAMILY-#OF UNITS: ❑ COMMERCIAL <br /> ELECTRICAL APPLICATION INFORMATION:4,DESCRIPTION.OF WORK <br /> CONTRACT PRICE OF WORK:$ ASSOCIATED BUILDING PERMIT#(if applicable): <br /> DESCRIBE SCOPE OF WORK: l v i ) Q b c d _. <br /> THIS INSTALLATION INCLUDES THE FOLLOWING SCOPE: (SELECT ALL THAT APPLY) �� <br /> LINE VOLTAGE WORK? `� NO ❑YES-Select Scope: ❑ Service CI Feeder CI Circuits-#: 43 El Complete Re-wire <br /> LOW VOLTAGE WORK? l NO ❑YES-#of Devices: <br /> SELECT SCOPE(REQUIRED): ❑ Data ❑ Intercom ❑Thermostat ❑Audio El 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:1Z NO ❑ YES--See Below&Pg.2 <br /> r[lBy 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: ❑NOIYES-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 /> CONTACT INFORMATION <br /> OWNER NAME: c'( Y�) Li' C•'�1 TENANT BUSINESS NAME(If Commercial): <br /> OWNER MAILING ADDRESS: STREET 4 ' a:s K L L")(. <br /> CITY Q-10 7 l, STATE VVV <br /> 1 A -L (' ZIP �� <br /> OWNER PHONE: f L S 1 y3`� ) ...,,.. OWNER EMAIL (,;4G'(1.0 1$..c.4 _(`�L Kt:'�"evvve` +++`i(. ?�..0'F. <br /> CONTRACTOR NAME: 3 +�h �� <br /> CONTRACTOR ADDRESS: STREET <br /> CITY STATE ZIP <br /> CONTRACTOR PHONE: CONTRACTOR EMAIL: <br /> CONTRACTOR LIC.#(REQUIRED): CITY OF EVERETT BUSINESS LIC.#(REQUIRED) <br /> PRIMARY CONTACT: CI OWNER ❑CONTRACTOR ❑OTHER(Please Specify) <br /> CONTACT NAME: CONTACT PHONE: <br /> CONTACT EMAIL: <br /> AGREEMENT:I 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 /> comply with the State Contractors Lai.?18.27 RCW and 296.200 WAC. City of Everett Official Use Only <br /> Pc,„ <br /> PERMIT#: <br /> O ner/Authorized A ent Signate Date (Revised 1/11/2019) Page 1-Application <br />