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<br /> ME
<br /> ® ELECTRICAL PERMIT APPLICATION
<br /> CITY OF EVERETT PERMIT SERVICES
<br /> EVERETT 3200 CEDAR STREET,EVERETT,WA 98201
<br /> WA5HINeTON (P)425-257-8810 I FAX 425-257-8857 I(E)evaretteps@evereltwa.gov I wwA'i.everettwa.gov/permits
<br /> PROJECT SITE INFORMATION
<br /> PROJECT ADDRESS: '5'2 1'i 2_ BUILDING AREA: sq ft
<br /> PROJECT TYPE: ❑ NEW CONSTRUCTION ❑ADDITION Lam!.'TENANT IMPROVMENT ❑REMODEL
<br /> BUILDING USE: Igi%FR El TOWNHOUSE ❑DUPLEX ❑ADU ❑MULTI-FAMILY-#OF UNITS: ❑COMMERCIAL
<br /> ELECTRICAL APPLICATION INFORMATION a. DESCRIPTION OF WORK
<br /> CONTRACT PRICE OF WORK:$ - cur) ASSOCIATED BUILDING PERMIT#(If applicable):
<br /> DESCRIBE SCOPE OF WORK: i'(tdt I i 2,`Y~,(,', (A,,, , , -{_\:,,,/. " r:t ,A, ",3L,:.,v`Y`.
<br /> THIS INSTALLATION INCLUDES THE FOLLOWING SCOPE: (SELECT ALL THAT APPLY)
<br /> LINE VOLTAGE WORK? ❑ NO YES-Select Scope:❑Service El Feeder ❑Circuits-#: ❑Complete Re-wire
<br /> LOW VOLTAGE WORK? l NO ❑YES-#of Devices:
<br /> SELECT SCOPE(REQUIRED): ❑Data ❑Intercom ❑Thermostat ❑Audio ❑Secure Access El 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: C NO ❑YES--See Below&Pg.2
<br /> By checking this box,I am stating that I have read and understand all of WAC 296-46B-9tl ,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: L$iO OYES-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: .{' t LA .- i'''- \--..tx-Vt ,V' TENANT BUSINESS NAME(If Commercial):
<br /> OWNER MAILING ADDRESS: STREET C 3(-`� ..rv\ P\`t
<br /> �{'',"y �,�`E,I�� 1 yr �q/' y
<br /> CITY '" 'e,.4- m }. STATE V-\!4A'T" ZIP "I tc;'0.1
<br /> OWNER PHONE: ,AN, -'1 '1`s L ( 4I OWNER EMAIL: dt cc,-V\t.::lice t-'O `J(Jo-tt ,t , ? L cie
<br /> CONTRACTOR NAME: fZ\(-6)(.X XICji L'\ke ``») 'tk.,<,... - c i\,(' it-'cLf
<br /> CONTRACTOR ADDRESS: STREET 2.` '..(at . Ci 6 ( f t .r' v��jj
<br /> CITY t • .tilt,.{ ' t STATE l"\l - zip )R?�'L+1)
<br /> CONTRACTOR PHONE: L.-t iJ) '1 47 ' .)i')t CONTRACTOR EMAIL: (`(V,"1 t:c,Y 6-1, (N -.)01 v"t A-41:1-Tri
<br /> CONTRACTOR LiG.#(REQUIRED): s, e'„1;.}s
<br /> (;i,/ f Z :2. C CITY OF EVERETT BUSINESS LIC,#(REQUIRED): .. CI )Ci.I5'7 r
<br /> PRIMARY CONTACT: !TOWNER ❑CONTRACTOR ❑OTHER(Please Specify)
<br /> CONTACT NAME: CONTACT PHONE: I, ")41 c:,: — (x 1 1 4>
<br /> y �/ t } CONTACT EMAiL: y f
<br /> {` i t �`��. eM} � �f��i,�i��.t C .' `•it`r+Y X.l?� tL...0 YY }
<br /> AGREEMENT:I hereby certify that 1 have read and examined this application and know the same to be true and cojrect. Ali proOsions 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 tam authorized by the owner of this properly to perform the work for which application is made and l
<br /> comply with the State Contractors aw 18.27 RCW and 296.200 WAC. City of Everett Official Use Only
<br /> PERMIT#:
<br /> Li (`f'(f li `•-' A ) r 7G_ t at 7 �( s L ,1 E i'�W I 3
<br /> L,,
<br /> ar/ArYthorized Agent Signature Date (Revised 1/11/2019) Page 1-Application
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