|
• •
<br /> 4k
<br /> EMI
<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 FAX425-257-8857 I(E)everetteps@everettwa.gov I www.everettwa.gov/permits
<br /> PROJECT SITE INFORMATION
<br /> PROJECT ADDRESS: ? 6l� +� ��/e,� I
<br /> -.�J ( \ 4 BUILDING AREA: 11OO sq ft
<br /> PROJECT TYPE: ❑ NEW CONSTRUCTION ❑ADDITION ❑TENANT IMPROVMENT ti,REMODEL
<br /> BUILDING USE: CSFR ❑TOWNHOUSE ❑ DUPLEX El ADU ❑ MULTI-FAMILY-#OF UNITS: ❑ COMMERCIAL
<br /> ELECTRICAL APPLICATION INFORMATION & DESCRIPTION OF WORK
<br /> CONTRACT PRICE OF WORK:$ c5c.. j�c ASSOCIATED BUILDING PERMIT#(if applicable):
<br /> .�.DESCRIBE SCOPE OF WORK: , 'r � L. c�� ;,,/,jT
<br /> THIS INSTALLATION INCLUDES THE FOLLOWING SCOPE: (SELECT ALL THAT APPLY)
<br /> LINE VOLTAGE WORK? El NO X.YES-Select Scope: El Service El Feeder ❑Circuits-#: Complete Re-wire
<br /> LOW VOLTAGE WORK? Cl NO ❑YES-#of Devices:
<br /> SELECT SCOPE(REQUIRED): El Data El 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 /> CODE COMPLIANCE
<br /> IS THIS PERMIT EDUCATION,INSTITUTIONAL, HEALTH AND/OR PERSONAL CARE FACILITIES: '\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-900,selected the specific reason on page 2
<br /> if 1...1
<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 SLYES-See Below&Pg. 3
<br /> ckPu RCW 19.28 , oey s s m eal w ou for et, ,
<br /> withoutrsuant theto proper electrical.261 licensingpr prt andowner certificationand ,or exemption.leaseholder cannot By checkingperfor el thisctric box, I am ork statingnb thatildings I haver n completed saleor lease 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:,, ,-- ',/ n oi,;via.z,-le v-t TENANT BUSINESS NAME(If Commercial):
<br /> OWNER MAILING ADDRESS: STREET 10 �tL 1— �J—
<br /> CITY E„/lif�,th' STATE Vv.✓' ZIP q1
<br /> OWNER PHONE: t�t7 '�1�� OWNER EMAIL:f�v�47t' ✓ k�' z��a' ri.;2 „ ,.,,, .,. ,...
<br /> �M,,f. ..._. . .. _ ,..... m R , a ., .��.-ssm-=. ,.�>..... ,.. ... . ,r.�_ r...,�� �y � ,., �., ice, K'
<br /> CONTRACTOR NAME: (e)v.r„\e
<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: jkl, WNER ❑CONTRACTOR ❑OTHER(Please Specify)
<br /> CONTACT NAME: CONTACT PHONE:
<br /> CONTACT EMAIL:
<br /> AGREEMENT:I hereby certify that 1 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 Law 18.27 RCW and 296.200 WAC. City of Everett Official Use Only
<br /> PERMIT,
<br /> ci /c...3' E \,(4,091— Ovl 0
<br /> Owner/Authorize Agent Signature ate (Revised 1/11/2019) Page 1-Application
<br />
|