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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@everettvia.gov I vrowr.everettwa.gov/permits <br /> - •PROAC.T`.SITE INFORMATION, <br /> PROJECT ADDRESS: D„� HCA)1'C&1q LL BUILDING AREA: sq ft <br /> PROJECT TYPE: ❑ NEW CONSTRUCTION ❑ADDITION ❑ TENANT IMPROVMENT ❑ REMODEL t'� JZ`/)A )D` <br /> BUILDING USE: ❑ SFR ❑TOWNHOUSE ❑ DUPLEX ❑ADU ❑ MULTI-FAMILY-#OF UNITS: COMMERCIAL <br /> ELECTRICAL APPLICATION�INF.O.RMATION':A'.DE3CRIPTION OF'WORK <br /> CONTRACT PRICE OF WORK:$ `j UbD ASSOCIATED BUILDING PERMIT#(if applicable): <br /> DESCRIBE SCOPE OF WORK: I� ✓ OL-,%140-14 r- Lr c i�tGt4L ,S G�Cv lc h <br /> 1^t� 0t' L GN U LAl-1-t T ALWt. l r-0tp` /2 _ftPpft� <br /> 5;Kvicr 7-P Et--/AL-L­ <br /> THIS INSTALLATION INCLUDES THE FOLLOWING SCOPE: (SELECT ALL THAT APPLY) <br /> LINE VOLTAGE WORK? ❑ NO LYES-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 AIL): <br /> CODE`COMPLIANCE , <br /> IS THIS PERMIT EDUCATION, INSTITUTIONAL,HEALTH AND/OR PERSONAL CARE FACILITIES: 0 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: ONO 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: h/ IN CLQ K11.1004< TENANT BUSINESS NAME(If Commercia): in)i!LL} M ILLLvje t< <br /> OWNER MAILING ADDRESS: STREET O' / 1p���/q LL I/(; - <br /> CITY Vi+ f STATE IVA ZIP (��♦J <br /> OWNER PHONE: h-r�5`) I �.� OWNER EMAIL: I,�A:-✓'_tl u f w LAI' we- <br /> CONTRACTOR NAME: A 14.L_ r L�zGT�2L< Q <br /> CONTRACTOR ADDRESS: STREET // <br /> CITY !,� V�ilLI�T STATE l� ZIP 0 •( D <br /> CONTRACTOR PHONE: 'I.2S^�S2�I �L' CONTRACTOR EMAIL: ..e v <br /> CONTRACTOR LIC.#(REQUIRED): 0r1 14 l.l=r=I l� CITY OF EVERETT BUSINESS LIC.#(RE IRED): <br /> PRIMARY CONTACT: 11 OWNER CONTRACTOR ❑OTHER(Please Specify) <br /> CO27YI, P4 <br /> T NAME: CONTACT PHONE: <br /> �� 1 !z�l '2 n1 _S 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 M <br /> �. 0- L2[inE Z3 2,L-t <br /> Owner/Authorized Agent Signature Date (Revised 4/5/2022) Page 1-Application <br />