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1111 EMI <br /> ELECTRICAL PERMIT APPLICATION <br /> CITY OF EVERETT PERMIT SERVICES <br /> EVERETT 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: 9-9 0 L' ( i Vt BUILDING AREA: sq ft <br /> PROJECT TYPE: ❑ NEW CONSTRUCTION ❑ADDITION ❑TENANT IMPROVMENT I=ZI REMODEL <br /> BUILDING USE: ZSFR ❑ TOWNHOUSE ❑ DUPLEX ❑ADU ❑ MULTI-FAMILY-#OF UNITS: ❑ COMMERCIAL <br /> ELECTRICAL APPLICATION INFORMATION & DESCRIPTION OF WORK <br /> CONTRACT PRICE OF WORK: $ r) ASSOCIATED BUILDING PERMIT#(if applicable): <br /> DESCRIBE SCOPE OF WORK: f Gttn ✓t, C I mo£ b2 ' F 1' 5 A'1'4�1 �i / /O <br /> THIS INSTALLATION INCLUDES THE FOLLOWING SCOPE: (SELECT ALL THAT APPLY) <br /> LINE VOLTAGE WORK? ❑ NO EYES-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 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 /> 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: 2/NO DYES-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>H�/ J i eN/A//�(S. TENANT BUSINESS NAME(If Commercial): <br /> OWNER MAILING ADDRESS: STREET /c)/ Z/ v+�i2(�/ZA?iZAJ«Jfl,- Z 4 / L/ <br /> CITY I(J iL/� IK=7. STATE Wiit ZIP 7g <br /> OWNER PHONE: , `f Gy" / OWNER EMAIL: J of/h,Jh t1 S.V, C C r <br /> b �t_)L. eeCONTRACTOR - <br /> 4/1 <br /> NAME: � <br /> CONTRACTOR ADDRESS: STREET 6 2 3 o L�f L� it� ✓t �/ <br /> CITY 1 t f7 \ 1/STATE ..k ZIP i <br /> CONTRACTOR PHONE:( s>23q-5f3/, CONTRACTOR EMAIL: dqa;1 f/d Jt,c"r1^%!. CZ 7/244-/ /)., 66 <br /> 10 <br /> CONTRACTOR LIC #(REQUIRED):/ . vc 7�� i �S �/l CITY OF EVERETT BUSINESS LIC (REQUIRED): <br /> PRIMARY CONTACT: ['OWNER [CONTRACTOR ❑OTHER(Please Specify) <br /> CONTACT NAME: CONTACT PHONE: / c` 39 5{" /( <br /> VII t,;'o Dan !77/0I CONTACT EMAIL: dc ek,r tecryt <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 arid ordinances governin his <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 /> E vor 61 <br /> Owner/Authorized Agent Signature Date (Revised 1/11/2019) Page 1-Application <br />