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11 ® • • <br /> MI ELECTRICAL PERMIT APPLICATION <br /> EVERETT CITY OF EVERETT PERMIT SERVICES <br /> 3200 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: ) )4 / L✓k i'1 Lam"( <- BUILDING AREA: C C ( sq ft <br /> PROJECT TYPE: El NEW CONSTRUCTION ❑ADDITION ❑TENANT IMPROVMENT Ix REMODEL <br /> BUILDING USE: K SFR ❑TOWNHOUSE El DUPLEX ❑ADU ❑ MULTI-FAMILY-#OF UNITS: _ ❑ COMMERCIAL <br /> ELECTRICAL APPLICATION INFORMATION & DESCRIPTION OF WORK <br /> CONTRACT PRICE OF WORK:$ b ASSOCIATED BUILDING PERMIT#(if applicable): <br /> DESCRIBE SCOPE OF WORK: /4,0.0 v j41 t L.. To (s,Lf,) 6 /4 1 t.L-- 44 J f /'`_7 <br /> C!'t(i ) ,,9_s J Oc 1-4 'L, , -+J,z 1-c 14 c lie-4, 1. -- /1, . 4 17-J e.0 e 27-- <br /> /L-6i' i cl-f <br /> THIS INSTALLATION INCLUDES THE FOLLOWING SCOPE: (SELECT ALL THAT APPLY) t <br /> LINE VOLTAGE WORK? ❑ NO 'YES-Select Scope: CI Service ❑ Feeder X Circuits-#: t ❑ Complete Re-wire <br /> LOW VOLTAGE WORK? ❑ NO ❑YES-#of Devices: <br /> SELECT SCOPE(REQUIRED): El Data ❑ Intercom ❑Thermostat El Audio ❑ Secure Access ❑ 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: .A,NO El 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 /> 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 RIYES-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 ;.)Z:.. 1 C._ -lt.S TENANT BUSINESS NAME(If Commercial): <br /> OWNER MAILING ADDRESS: STREET <br /> 3c 2 L6 ill ) j- 1.4, <br /> j7j <br /> CITY p/-t C•l_ STATE �'�-"T,Q ZIP /Z% V) <br /> OWNER PHONE (V1) ) y 7( --t ,3 S OWNER EMAIL _J-4J,O 7t-:". '1't1 C 6., 7'd it ( /'-1 <br /> CONTRACTOR NAME: <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: [OWNER ❑CONTRACTOR ❑OTHER(Please Specify) ) <br /> CONTACT NAME: CONTACT PHONE: (y,,I)') j 1J- 6 S S <br /> ,' 4)6 1 1-7)c) 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 Law 18.27 RCW and 296.200 WAC. City of Everett Official Use Only <br /> PERMIT#: <br /> erlAuthorized Aggr(tgnature Date (Revised 1/11/2019) Page 1-Application <br />