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i <br /> ELECTRICAL PERMIT APPLICATION [� <br /> CITY OF EVERETT PERMIT SERVICES <br /> EVERETT 3240 CED) R STREET,EVERETT,INA 813201 <br /> ivasHrrlctroN (P)425=257:81110 j FAX 425:257=885''7`.((E).everatt©pstineveroltwa:gov j wNnrr,evereltwa.govlperrnils <br /> .77 <br /> PROJECT ADI7RESSt 0--A .e, 16UiLRIN ARBA: 84 ft <br /> PROJEGT`T1lPi : Q.NEW CONSTRUCTION .Q ADDITION ❑TENANT IMPROVMENTREM- ODEL <br /> BUILDINt3 USE( SFR ❑TONINHQUSE ❑DUPLEX: Q AD U ❑MU171 FAMILY 1f QF IJNI fS; 1TPQFAMERQI4 <br /> s EII.ECT111W., APIRL 0 RTTICK , <br /> QF MRK=_ <br /> CONTRACT PRICE OF.WORK:$ 10 O'Q 10,50CIATIED BJJILDING PERMIT#(it applicable): <br /> 1 ; . . <br /> DESCRIBE PCOEE OF WORK: 4CU. r <br /> THIS INSTALLATION INCLUDES THE FOLLO ING SCOPE:(SELECT ALL THAT".APPLY) <br /> ,LINE.Vb TAOE WOOR? Q NO YES.-Select.Scopc Q Service [].Feeder Crcilits-#;. Q.Gompl06 Re=wire <br /> LOW VOLTAGE WORK? J.NO Q YES-it.of Devices: <br /> SELECT SCOPE'(REQUIRED): ❑Ejafa Q Intefcctti Q`Thirnios141 ❑Audio ❑Seoure Access ❑SecuriEy System <br /> Q Ore Alarm•111stallaltons under this permit only include electrical wiriAg rough-ire of th8.syslem;An adciltional.• <br /> Fire Alarm.Permll is required for review of device location and lnstgllalion approval. <br /> Q Other(List All): <br /> .,e:t• t! `��:2). ?� t. { -. Tl1 � ����� ��I/.��..r }K�� �i Y1 451F'. <br /> IS THIS PERMIT EDUCATION, INSTITUTIONAL,HEALTH ANWOR PERSONAL CARE FACILITIES NOYES`-:;SeH Below&Pg 2 <br /> QBy`checking this,box, I ani stating•thiifl hove read'and uhdorsWid.611 of WAC 196-4813 gUD,:88I$Ct6fI 1118 3006the reason on.pe.0e,2 <br /> .'Of'this a00110ation'(se4.h$)st pago),AND Plan Review Is NOT required`because l.meet all bf the following sub sections Ilial do not <br /> $oo Ppgo 2 require plan,Ragiew. <br /> ARE YOU AN OWNER 0ER'156AMINd WbRK Ae THE cONTRACTOk WITHOUT ELECTRICAL LICENSURE: NQ YES,-See Below&.P'g.3• <br /> QPursuarft to RCW 18.28,281,prbperiy owners and leaseholders cannot perform electrical work on buildings for rent,sale,or leas..o <br /> without the proper.electrical llbensirig and certification,or exemptloh.By checking this box,I em staterg that 1 have compleled;arid <br /> See Page.8 .slgned the AFFIDAVIT on page 3,of this.apptiaatl6h. to recelVe an eicemplibn from this lfcerisiriglcertificaUan req.wromen1 <br /> 9N T.A T;J—. <br /> IIQ:N l <br /> OWNER NAME;.; a <br /> SSS 0 TENANT BUSINESS NAME(If Commercial),, <br /> OWNER MAILING ADDRESS: STREET <br /> srnrs <br /> OWNER PHONE: ch, OWNER EMAIL: ZIP <br /> CONT12A&TOR NAME: <br /> CONTRACTOR ADDRE$Ss Sineer <br /> t <br /> ern C /`lL;�i-�-e srnYe 41 '.e( `7 7 <br /> CONTRACTOR PHONE: 533(039.. ONTRACTOR WMAIL: /1".,.. -6— <br /> CONTRACT4R.LIC.#(REQUIREo) PrG-L;Cr- cs � CITY.OF EVERETT BUSINESS LIC. #(REQUIRCD):., <br /> PRIMARY CONTACT: ❑t1WNEF2 ONTRACTbR QOTHER(Please Specify) <br /> CONTACT NAME: CONTACT PHONE, jv6 .-�,T-5, <br /> CONTACT EMAIL: J .F CL'-t✓(_ � Iee -,�� !pZt. !'�.J� 3 <br /> oRt t tifCNT:J haiehy cer r y shat 1 havo yea. end oxamiood 1hls app!catfan and know f to seme.to e e ar1fJ correct, AR provisions of fakes and nrdirra+tcos govorning this <br /> NO cif work will be Completed whethat rpoci'fbB heroin or not. The gmnting of a pormlf dons rrol presunto!o give aufltority,to Yialoto or conCoJ the pravislons:of prry other statti'or <br /> l000l taw roflulsNng canatructiwt pr[ho pertormanco of co»;slrpcdon: That!am apfhorized ay the ower bl;his property to porlorm the work for whJ oh erppllgaligri is inada anti! <br /> oorriply wi h:lha.Slale.C&tract64 Law 18;27 PCW and 296:200 WAC: CHY of Evorolt'OHICIAI ueo.Onl <br /> RERMt '#: <br /> 0 'narlAut ed Agont Stpnaturo Date (t7evised 1/1!/2079) Pagwl-App116;1t1on <br />