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ELECTRICAL PERMIT APPLICATI 'ECEOVE CITY OF EVERETT PERMIT SERVICES EVERETT 32FEB 19 2023 00 CEDAR STREET,EVERETT,WA 98201 WASHINGTON (P)425-257-8810 1 FAX 425-257-8857 1(E)everetteps@everetlwa.govI wmv.everettwa. v rmits PROJECT SITE INFORMATION PROJECT ADDRESS: 0 QVILANP VC r--V r `V\I A BUILDING AREA: q jr&rMI1_�0rVIL;,U,:5ft PROJECT TYPE: NEW CONSTRUCTION ❑ADDITION ❑TENANT IMPROVMENT ❑ REMODEL BUILDING USE: ❑SFR ❑TOWNHOUSE ❑ DUPLEX ❑ADU ❑ MULTI-FAMILY-#OF UNITS: ❑COMMERCIAL ELECTRICAL APPLICATION INFORMATION & DESCRIPTION OF WORK CONTRACT PRICE OF WORK:$'ZC'V ' ASSOCIATED BUILDING PERMIT#(if applicable): DESCRIBE SCOPE OF WORK: U;UF&r 1�j S r 5U0 Ppo-in- I-p Ito ejorLcrs, THIS INSTALLATION INCLUDES THE FOLLOWING SCOPE: (SELECT ALL THAT APPLY) LINE VOLTAGE WORK? ❑NO 7 YES-Select Scope:Z Service ❑ Feeder ❑Circuits-#: ElComplete Re-wire LOW VOLTAGE WORK? Elr NO tZ YES-#of Devices: 2, SELECT SCOPE(REQUIRED): ❑ Data ElIntercom ❑Thermostat -1 Audio ❑Secure Access El Security System ❑ Fire Alarm-Installations under this permit only include electrical wiring rough-in of the system.An additional Fire Alarm Permit is required for review of device location and installation approval. C70ther(List All): (y a484.•JE Zt'(1 L 0 Pt=Nr JZ S CODE COMPLIANCE IS THIS PERMIT EDUCATION,INSTITUTIONAL,HEALTH AND/OR PERSONAL CARE FACILITIES: NO YES--See Below&Pg.2 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 of this application(see next page),AND Plan Review is NOT required because I meet all of the following sub sections that do not See Page 2 require Plan Review. ARE YOU AN OWNER PERFORMING WORK AS THE CONTRACTOR WITHOUT ELECTRICAL LICENSURE: NO YES-See Below&Pg.3 © Pursuant to RCW 19.28.261,property owners and leaseholders cannot perform electrical work on buildings for rent,sale,or lease without the proper electrical licensing and certification,or exemption.By checking this box, I am stating that I have completed and See Page 3 signed the AFFIDAVIT on page 3 of this application to receive an exemption from this licensing/certification requirement. CONTACT INFORMATION OWNER NAME: tJ h/ I LL_ TENANT BUSINESS NAME(If Commercial): OWNER MAILING ADDRESS: 7 (16EET t�YVTI-JD 1 - oe - w g CITY STATE ZIP OWNER PHONE: - Jr J'L -71 wy OWNER EMAIL: JjCrA CONTRACTOR NAME: to 4--e- CONTRACTOR ADDRESS: STREET CIN STATE ZIP CONTRACTOR PHONE: CONTRACTOR EMAIL: CONTRACTOR LIC.#(REQUIRED): CITY OF EVERETT BUSINESS LIC.#(REQUIRED): PRIMARY CONTACT: JZOWNER ❑CONTRACTOR ❑OTHER(Please Specify) CONTACT NAME: CONTACT PHONE: CONTACT EMAIL: AGREEMENT:1 hereby certify that t have read and examined this application and know the same to be true and correct. A#71rovisions of laws and ordinances governing this 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 local law regulating construction or the performance of construction. That 1 am authorized by the owner of this property to perform the work for which application is made and/ comply with the State Contractors Law 18.27 RCW and 296.200 WAC. City of Everett Official Use Only PERMIT#: Dn�ATAWi&Fzeid Agerfit gignatdre Date (Revised 1/11/2019) Page 1-Application I V ,� 2 o /- lo(,�,