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EVERETT WASHINGTON ELECTRICAL PERMIT APPLICATION CITY OF EVERETT PERMIT SERVICES 3200 CEDAR STREET. EVERETT. WA 98201 (P) 425-257-8810 1 FAX 425-257-8857 1 (E) everetteps@everettwa.gov I www.everettwa.gov/permits PROJECT SITE INFORMATION PROJECT ADDRESS: q�/ �% A S'LJ BUILDING AREA: sq ft PROJECT TYPE: C.NEW CONSTRUCTION ❑ ADDITION ❑ TENANT IMPROVMENT ❑ REMODEL BUILDING USE: [9SFR ❑ TOWNHOUSE ❑ DUPLEX ❑ ADU ❑ MULTI -FAMILY - # OF UNITS: ❑ COMMERCIAL ELECTRICAL APPLICATION INFORMATION & DESCRIPTION OF WORK CONTRACT PRICE OF WORK: $ ASSOCIATED BUILDING PERMIT # (if applicable): DESCRIBE SCOPE OF WORK: THIS INSTALLATION INCLUDES THE FOLLOWING SCOPE: (SELECT ALL THAT APPLY) LINE VOLTAGE WORK? ❑ NO YES - Select Scope: ❑ Service ❑ Feeder ❑Circuits-#: ❑ Complete Re -wire LOW VOLTAGE WORK? I❑7 NO P YES- # of Devices: SELECT SCOPE (REQUIRED): Data ❑ Intercom FR Thermostat ❑ Audio ❑ Secure Access 0 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): CODE COMPLIANCE IS THIS PERMIT EDUCATION, INSTITUTIONAL, HEALTH AND/OR PERSONAL CARE FACILITIES: [' 'NO F1 YES -- See Below & Pg. 2 ❑ By checking this box, I am stating that I have read and understand all of WAC 296-46113-900, 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 YES -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. CONTACT INFORMATION OWNER NAME: t,, ► t� c. TENANT BUSINESS NAME (If Commercial): OWNER MAILING ADDRESS: STREET % c CITY STATE ZIP OWNER PHONE: OWNER EMAIL: CONTRACTOR NAME: CONTRACTOR ADDRESS: STREET CITY STATE ZIP CONTRACTOR PHONE: CONTRACTOR EMAIL: CONTRACTOR LIC. #(REQUIRED): CITY OF EVERETT BUSINESS LIC. #(REQUIRED): PRIMARY CONTACT: ArOWNER ❑CONTRACTOR ❑OTHER (Please Specify) CONJAYT NAME: / / Cyvt /il�'C (��"_ CONTACT PHONE:11�' 1 CONTACT EMAIL: AGREEMENT. l hereby certify that 14fave read and examined this application and know the yEfine to be true and eerfeot/All provisions of IawSalfd ordinances governing this type of work will be completed whether specified herein or not. The granting of a permit d es not presume to give authority to violate or cancel the provisions of any other state 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��-05� Own /Authori d Aged Signature Date (Revised 1/1112019) Page 1-Application