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ELECTRICAL PERMIT APPLICATION v CITY OF EVERETT PERMIT SERVICES EVERETT 3200 CEDAR STREET,EVERETT,WA 98201 WASHINGTON (P)425-257-8810 1(E)PermttServices@evereltwa.gov I www.everettwa.gov/permits -PROACT:SITE INFORMATION. PROJECT ADDRESS: BUILDING AREA: /� sq ft PROJECT TYPE: ❑ NEW CONSTRUCTION ❑AQQITION ❑TENANT IMPROVMENT ❑ REMODEL ( jl � BUILDING USE: ❑ SFR ❑TOWNHOUSE ❑ DUPLEX ❑ADU ❑ MULTI-FAMILY-#OF UNITS: ❑ COMMERCIAL . ELECTRICAL APPLI ATION.INFORMAT.ION`&.DESCRIPTION OF'WORKI CONTRACT PRICE OF WORK:$ ASSOCIATED BUILDING PERMIT#(if applicable): DESCRIBE SCOPE OF WORK: c 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? ❑ 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 d insta ation approval. Other(List All): - C CODE COMPLIANCE ' IS THIS PERMIT EDUCATION, INSTITUTIONAL,HEALTH AND/OR PERSONAL CARE FACILITIES: -lam YES See Below&Pg.2 ❑ By checking this box, I am stating that I have read and understand all of WAC 296-46B- 00,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 DYES-See Below&Pg. 3 ElPursuant 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. -77 ' C 77. ONTACT INFORMATION OWNER NAME: TENANT BUSINESS NAME(If Commercial): OWNER MAILING ADDRESS: STREET CITY STATE ZIP OWNER PHONE: OWNER EMAIL: CONTRACTOR NAME: Co- To CONTRACTOR ADDRESS: STREET G/ CITY A�ayzSTATE ZIP i PHONE: CONTRACTOR EMAIL: CONTRACTOR LIC.#(REQUIRED): ICITY OF EVERETT BUSINESS LIC.#(REQUIRED): PRIMARY CONTACT: OWNER ❑CONTRACTOR ❑OTHER(Please Specify) CONT CT N ME: DD CONTACT PHONE: —ij r CONTACT EMAIL: 142, AGREEMENT.•I hereby certify that I have read and examined this application and know the same to be true and correct. AI!provisions of laws ane6s 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 performance of construction. That I am authorized by the owner of this properly to perform the work for which application is made and/ compl th tlri�Ste`ContrestQrs w 18.27 RCW and 96.200 WAC. City of Everett Official Use Only PERMIT#: Owe Authorized Agent Sig ture Date (Revised 41512022) Page 1-Application