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ELECTRICAL PERMIT APPLICATION <br /> CITY OF EVERETT PERMIT SERVICES <br /> EVERETT 3200 CEDAR STREET,EVERETT,WA 98201 <br /> WASHINGTON (P)425-257-8810 1(E)PermitServices@everetlwa.gov I www.everettwa.gov/permits <br /> PROJECT SITEINFORMATION <br /> PROJECT ADDRESS: / '�j 61tr �' �d BUILDING AREA: Ud J sq ft <br /> PROJECT TYPE: ❑ NEW CONSTRUCTION ❑ADDITION ❑TENANT IMPROVMENT OREMODEL <br /> BUILDING USE: ❑SFR []TOWNHOUSE ❑DUPLEX ❑ADU ❑MULTI-FAMILY-#OF UNITS: COMMERCIAL <br /> ELECTRICAL APPLICATION INFORMATION & DESCRIPTION OF WORK <br /> CONTRACT PRICE OF WORK:$ f�U v•� ASSOCIATED BUILDING PERMIT#(if applicable): <br /> DESCRIBE SCOPE OF WORK: <br /> �l <br /> � -. .v, v / tel« I ✓— 7061 <br /> i <br /> THIS INSTALLATION INCLUDES THE FOLLOWING SCOPE: (SELECT ALL THAT APPLY) <br /> LINE VOLTAGE WORK? [I NO R]YES-Select Scope:®Service Feeder ❑Circuits-#: ❑Complete Re-wire <br /> LOW VOLTAGE WORK? [,5 NO ❑YES-#of Devices: <br /> SELECT SCOPE(REQUIRED): ❑Data ❑Intercom ❑Thermostat ❑Audio ❑Secure Access ❑Security Syst2m <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 /> ❑Other(List All): <br /> CODE COMPLIANCE <br /> IS THIS PERMIT EDUCATION,INSTITUTIONAL, HEALTH AND/OR PERSONAL CARE FACILITIES: EdNo YES--See Below&Pg.2 <br /> ❑ By checking this box, I am stating that I have read and understand all of WAC 296468-900,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 P1'ES-See Below&Pg. <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: 4!:� X p TENANT BUSINESS NAME(If Commercial): <br /> OWNER MAILING ADD ESS: STREET �5!2­4eooJ (JLC V••4, <br /> CITY �(/�-e/e% / STATE 4,,14 ZIP Cerci <br /> OWNER PHONE: L�2S� v��7- Y6 X0 OWNER EMAIL: <br /> CONTRACTOR NAME: / <br /> CONTRACTOR ADDRESS: STREET v <br /> CITY (•�! STATE 21P <br /> CONTRACTOR PHONE: '-12-1-.Z S- 7.-Z619 Id CONTRACTOR EMAIL: �L�r` 7_ ,? _ <br /> CONTRACTOR LIC.#(REQUIRED): CITY OF EVERETT BUSINESS LIC.#(REQUIRED): <br /> PRIMARY CONTACT: ZWNER ❑CONTRACTOR E]OTHER(Please Specify) <br /> CONTACT NAME: CONTACT PHONE: �Z S` (� -70 <br /> CONTACT EMAIL: k` . 14 �' , <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 goverrAg 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 <br /> or local law regulating construction or the performance of construction. That Ian)authorized by the owner of this property to perform the work for which application is made and/ <br /> comply v'lh e S104 Co actors Law 18.27 RCW and 296.200 WAC. City of Everett Official Use Only <br /> PERMIT#: <br /> ZZ E 23c� i <br /> Owner/ orize gent Signature Date (Revised 4/5/2022) Page 1-Application <br />