Laserfiche WebLink
0 <br />ELECTRICAL PERMIT APPLICATION <br />E V E R E T T CITY OF EVERETT PERMIT SERVICES <br />3200 CEDAR STREET, EVERETT, WA 98201 <br />WA.UI J Tt . (P) 425-257.8810 1 (E) PermitServlces@everettwa.gov I www.everattwa.gov/permits <br />PROJECT SITE INFORMATION <br />PROJECT ADDRESS; 4 Vtret 'I,LP (W W i <br />BUILDING AREA: {29_ so ft <br />PROJECT TYPE; ❑ NEW CONSTRUCTION ❑ADDITION ❑TENANT IMPROVMENT REMODEL 4, t LV <br />BUILDING USE: ❑ SFR ❑ TOWNHOUSE ❑ DUPLEX ❑ ADU ❑ MULTI -FAMILY - # OF UNITS; NcOMMERCIAL <br />ELECTRICAL APPLICATION INFORMATION & DESCRIPTION OF WORK <br />CONTRACT PRICE OF WORK: $ <br />ASSOCIATED BUILDING PERMIT # (if applicable): <br />DESCRIBE SCOPE OF WORK: <br />THIS INSTALLATION INCLUDES THE FOLLQYVING SCOPE: SELECT ALL THAT APPLY <br />LiNE VOLTAGE WORK? 0 J_rS - Select Scope: ❑ Service ❑ Feeder ❑ Circuits-#: ❑ 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 <br />additional Fire Alarm Permit is required for review of device location and installation approval. <br />Yal Other (List All): i <br />CODE COMPLIANCE <br />IS THIS PERMIT EDUCATION, INSTITUTIONAL, HEALTH AND/OR PERSONAL CARE FACILITIES: MNO DYES— See Below & Pg, 2 <br />❑ By checking this box, I am stating that I have read and understand all of WAC 296.46B-90, selected the specific reason on page <br />2 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 aES -See Below & Pg. <br />❑ Pursuant to RCW 19.28.261, property owners and leaseholders cannot perform electrical work on bui dings 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: TENANT BUSINESS NAME If Commercial): Lz <br />OWNER MAILING ADDRESS: STREET E7'� CLf± (4� I I <br />t, <br />CITY G STATE 1AJA ZIP 4V <br />OWNER PHONE:. <br />OWNER EMAIL: ±=Iie1 01 C- <br />CONTRACTOR NAME: �J -9 <br />CONTRACTOR ADDRESS: STREET Z 5' � A V <br />CITY STATE ZIP a <br />CONTRACTOR PHONE: S Z ]CONTRACTOR <br />EMAIL: '3 C'my ) <br />CONTRACTOR LIC. #(REQUIRED): ITY OF EV RETT <br />USINESS LIC. #(REQUIRED): r% <br />PRIMARY CONTACT: ❑OWNER ❑CONTRACTOR %OTHER (Please Specify) <br />CONTACT NAME: <br />CONTACT PHONE: ' <br />CONTACT EMAIL: <br />AGREEMENT., I hereby certity that i have read and examined rms application and Know me some robe true and cdrreu+. <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 <br />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/ <br />comply with the State Contractors Law 18.27 RCW and 296.200 WAC. Cyr of Everett Official Use Only <br />PERMIT #: <br />E <br />nerl thor cl Agent Signature Pate (Revised 4/512022) Page 1-Application <br />