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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 1 www.everettwa.gov/permits PROJECT-'.SITE INFORMATION.; PROJECT ADDRESS: L (; Z �j t, BUILDING AREA: sq ft PROJECT TYPE: ❑ NEW CONSTRUCTION ❑ADDITION 21 TENANT IMPROVMENT ❑ REMODEL BUILDING USE: RSFR ❑TOWNHOUSE ❑ DUPLEX ❑ADU ❑ MULTI-FAMILY-#OF UNITS: ❑ COMMERCIAL ELECTRICAL APPLICATION �INFORMAT.ION &'DESCRIPTION'''OF WORK CONTRACT PRICE OF WORK: $ ? Ce C% ASSOCIATED BUILDING PERMIT#(if applicable): DESCRIBE SCOPE OF WORK: e (,-s Pv.c,t THIS INSTALLATION INCLUDES THE FOLLOWING SCOPE: (SELECT ALL THAT APPLY) LINE VOLTAGE WORK? ❑ NO YES-Select Scope: tat_.5ervice ❑ Feeder ❑ Circuits-#: ❑Complete Re-wire LOW VOLTAGE WORK? NO ❑YES-#of Devices: SELECT SCOPE(REQUIRED): ❑ Data ❑ Intercom ❑Thermostat ❑Audio ❑ Secure Access ❑ 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. ❑ Other(List All): COPR COMPLIANCE IS THIS PERMIT EDUCATION, INSTITUTIONAL,HEALTH AND/OR PERSONAL CARE FACILITIES: RNO 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:PNO OYES-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. ,AA �CONT4ICT 1.NFORMATI0N OWNER NAME: �--`""l J't C 4ZZj c TENANT BUSINESS NAME(if Commercial): OWNER MAILING 4L ADDRESS: �Z STREET ' ^i L'-(/"- CITY '� 1 [ rr STATE ZIP OWNER PHONE: < k OWNER EMAIL: I<D C l ti. S'C J' CG`-► L'1 CONTRACTOR NAME: z- � �C CONTRACTOR ADDRESS: STREET f 4/ �? `,i4� Z 7e u r./ '-V-� l CITY G1 STATE , ZIP CONTRACTOR PHONE: Zcct `-1'7.Z CONTRACTOR EMAIL: L6 CCa1(1/111 s'`��e' , `�� CONTRACTOR LIC.#(REQUIRED): e C?01 PZ—/'S YS-JI)rq CITY OF EVERETT BUSINESS LIC.#(REQUIRED): 3� PRIMARY CONTACT: ❑ OWNER ,CONTRACTOR ❑OTHER(Please Specify) CONTA T NAZ NAME: ( ^^ CONTACT PHONE: D4 4-1 Z IJ CONTACT EMAIL: L�➢ L` - ; ,&V AGREEMENT:I hereby certify that/have read and examined this application and know the same to be true and correct. All provisions o 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 performa of constru�re That I am authorized by the owner of this property to perform the work for which application is made and I comply with the State Contract Law 8 27 nd 98:200 AC. City of Everett Official Use Only PERMIT#: %l zdL E ) oj Owner/Authorized Agent Signatur ate (Revised 4/5/2022) Page 1-Application