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<br /> mil ELECTRICAL PERMIT APPLICATION
<br /> CITY OF EVERETT PERMIT SERVICES
<br /> EVERETT 3200 CEDAR STREET,EVERETT,WA 98201
<br /> WASHINGTON (P)425-257-8810 I FAX 425-257-8857 I(E)everetteps@everettwa.gov I www.everettwa.gov/permits
<br /> '' ; PROJECTS1TE INFORIVIATION '`
<br /> PROJECT ADDRESS: I Q�3 gi-44 / ""-'' J 6- BUILDING AREA:_____1: 000 sq ft
<br /> PROJECT TYPE: ❑ NEW CONSTRUCTION ❑ADDITION ❑TENANT IMPROVMENT ijgREMODEL
<br /> BUILDING USE: ,SFR ❑TOWNHOUSE ❑ DUPLEX ❑ADU ❑ MULTI-FAMILY #OF UNITS: ❑ COMMERCIAL
<br /> ELECTRICAL APPLICATION INFORMATION &DESCRIPTION OF WORK
<br /> `=
<br /> CONTRACT PRICE OF WORK:$ "SO 0 / ASSOCIATED BUILDING PERMIT#(if aoolicable):
<br /> DESCRIBE SCOPE OF WORK: -,�IQT ��Cil'yIO���``
<br /> aa rAvA/J7 fim&i,,,,,,,,,i 6.(1:- /-1-te /-1-6e.„9-f
<br /> _ t,P-- a ,i,./-1,-, 'z'' 'oLet-1,47 , 4....,-- i
<br /> THIS INSTALLATION INCLUDES THE FOLLOWING SCOPE: (SELEM ALL THAT APPLY) U V v
<br /> LINE VOLTAGE WORK? ❑ NO ❑YES-Select Scope:-Service ❑ Feeder ❑Circuits-#: /0 ❑Complete Re-wire
<br /> LOW VOLTAGE WORK? ❑ NO ❑YES-#of Devices:
<br /> SELECT SCOPE(REQUIRED): /•,11tIata 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 All):
<br /> .CODE:COMPLIANCE
<br /> IS THIS PERMIT EDUCATION, INSTITUTIONAL,HEALTH AND/OR PERSONAL CARE FACILITIES: Ili . O I[J YES--See Below&Pg.2
<br /> PBy checking this box,I am stating that I have read and understand all of WAC 296-46B-9''0,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: Mo DYES-See Below&Pg.3
<br /> Pursuant to RCW 19.28.261,property owners and leaseholders cannot perform electrical work on •uildings 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: l�al L k j/ e c 4:15ENANT BUSINESS NAME(If Commercial): 1-4 / E.- "'" (/e
<br /> OWNER MAILING ADDRESS: STREET 17 9 33 /gN14'0od /z-i �J/� �/G�/�J,
<br /> t •, CITY STATE /��/�`r 2
<br /> OWNER PHONE: (1'29'fV "_/cf (owNER EMAIL
<br /> CONTRACTOR NAME: J ��/�iLArC� C
<br /> CONTRACTOR ADORES • STREET =Z� //t f -I
<br /> :> CITY 1% STATE 97,oze,,off I I,,,.
<br /> CONTRACTOR PHONE o (y 6'!—c2w CONTRACTOR EMAIL: '4 .. "� '' ,/I( ' "
<br /> R SINE SS LIC.#(RE ED): . ., .
<br /> Yj ���►.3l�S CITY o�����
<br /> CONTRACTOR LIC #( QUIR ) EC �
<br /> PRIMARY CONTACT: ❑OWNER 0 •NTRACTOR ❑OTHER(Please Specify)
<br /> CON CT NAME: p ilez CONTACT PHONE: d"06 %,` — 6' /f
<br /> CONTACT EMAIL: ' L%I4 /'Y!- r , e...7,71
<br /> AG EMENT:1 e eby certify f t 1 have read and examined this application and know the s to be tru n orrec All provisions of I.Ornd ordinances governing this
<br /> type of work will completed erein or not. The granting of a permit doe of pres gauthority um o i e to violate or cahe provisions of any other state or
<br /> local law regulating cons ion or the performanc 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 St Contractors Law 18.27 RC and 296.200 WAC. City of Everett Official Use Only
<br /> PERMIT#:
<br /> r ( 1-' / E iitif nq / -.) _( ,
<br /> ner/Authorized Agent Signature Date (Revised 1/11/2019) Page 1-Application
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