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ELECTRICAL PERMIT APPLICATION CITY OF EVERETT PERMIT SERVICES EVERETT 3200 CEDAR STREET,EVERETT,WA 98201 WASHINGTON (P)425-257-8810 1(E)PermitServices@everettwa.gov I www.everettwa.gov/permits PROJECT SITE INFORMATION PROJECT ADDRESS: j'11& BUILDING AREA: Of sq ft PROJECT TYPE: ❑ NEW CONSTRUCTI N ❑ADDITION ❑TENANT IMPROVMENT ❑REMODEL BUILDING USE: ❑SFR [:]TOWNHOUSE ❑ DUPLEX ❑ADU ❑MULTI-FAMILY-#OF UNITS: COMMERCIAL ELECTRICAL APPLICATION INFORMATION A DESCRIPTION OF WORK CONTRACT PRICE OF WORK: $ q. ASSOCIATED BUILDING PERMIT#(if applicable): DESCRIBE SCOPE OF WORK: P THIS INSTALLATION INCLUDES THE FOLL ING SCOPE: (SELECT ALL THAT APPLY) LINE VOLTAGE WORK? ❑ NO � 9.YE KYES-Select Scope: ❑Service 11 Feeder E] Circuits-#: ❑Complete Re-wire LOW VOLTAGE WORK? ❑ NO � S-tt of Devices: I SELECT SCOPE(REQUIRED)% F-91 ata/ ❑Intercom E]Thermostat ❑Audio E]Secure Access ❑Security System ire 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. ❑Other(List All): CODE COMPLIANCE IS THIS PERMIT EDUCATION, INSTITUTIONAL, HEALTH AND/OR PERSONAL CARE FACILITIES: NO UYES--See Below&Pg. 2 ❑ By checking this box, I am stating that I have read and understand all of WAC 296-4613-900,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 ES See Below&Pg. F-1Pursuantto 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: L TENANT BUSINESS NAME(If Commercial): OWNER MAILING ADDRESS: STREET V CITY / ff STATE ,,//ZIP OWNER PHONE: �I WNER EMAIL: Q Vera e CONTRACTOR NAME: CONTRACTOR ADDRESS: STREET 1-7 CITY✓ STATE itA141 ZIP O� CONTRACTOR PHONE — J ONTRACTOR EMAIL: U0 a'm 77 CONTRACTOR LIC.#(REQUIRED CIT F EVERETT BUSINESS LIC.#(REQUIRED): PRIMARY CONTACT: ❑OWNERGONTRACTOR [-]OTHER(Please Specify)_ CONTACT NA CONTACT PHONE: n n` ,r `rnI f 1� CONTACT EMAIL: 1 t GR EMENT./hereby certify that I have read rd examined this application and knov fh same to be true and come - At provisions of laws and ordinances governing this type of work will be completed whether specific herein or not. The granting of a perms es not presume to give authority to violate or cancel the provisions of any other stale or local law regulating construction or the performance of construction. That/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#: (� E O7u6or_iz_edbV,7rtjre Date (Revised 4/5/2022) Page 1-Application