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ELECTRICAL PERMIT APPLICATION <br /> CITY OF EVERETT PERMIT SERVICES <br /> 3200 CEDAR STREET EVERETT,WA 98201 <br /> (P)425-257-8810 1 FAX 425-257-8857 1(E)everettey�pryps@evperrettwa�a.gov www.everettwa.gov/perMits <br /> - <br /> _.. e• 5 BUILDING AREA: sq ft <br /> PROJECT ADDRESS: <br /> PROJECT TYPE: U NEI CONSTRUCTION ®ADDITION WTENANT IMPROVMENT ®REMODEL <br /> BUILDING USE ®SFR ®TOWNHOUSE ®DUPLEX ADU ®MULTI-FAMILY #OF UNITS'.— COMMERCIAL <br /> qrx <br /> CONTRACT PRICE OF WQRK:$ ASSOCIATED BUILDING PERMIT#(if applicable): <br /> DESCRIBE SCOPE OF WORK- eC *e.6e I e <br /> THIS INSTALLATION INCLUDES THE FOLLOWING SCOPE:(SELECT ALL THAT APPLY) <br /> LINE VOLTAGE WORK? ®NO YES-Select Scope:®Service ®Feeder ®Circuits-#: ®Complete Re-wire <br /> LOW VOLTAGE WORK? §VO YES-#of Devices: <br /> SELECT SCOPE(REQUIRED): ®Data [3 intercom 0 Thermostat [3 Audio ®Secure Access e 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 /> - irs. <br /> IS THIS PERMIT EDUCATION,INSTITUTIONAL,HEALTH AND/OR PERSONAL CARE FACILITIES O YES See Below&Pg.2 <br /> By checking this box,I am stating that I have read and understand all of WAC 296-46B-900, all <br /> Elected 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: NO YES-See Below&Pg.3 <br /> ® Pursuant to RCW 19.28.261,property owners and leaseholders cannot perform electrical work on b it ings for rent,sate,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 ticensmg/certification requirement <br /> r r € taffil <br /> Tz <br /> OWNER NAME: _ 1 TENANT BUSINESS NAME if Commercial): P <br /> dA <br /> OWNER MAILING ADDRESS: STREET <br /> • STATE • ZIP <br /> CITY <br /> OWNER PHONE: OWNER EMAIL: <br /> • <br /> CONTRACTOR NAME: <br /> CONTRACTOR ADDRESS: STREET • <br /> STATE r ZIP <br /> CONTRACTOR PHONE: CONTRACTOR EMAIL: C ` <br /> CONTRACTOR LIC.#(REQUIREDj: CITY OF EVERETT BUSINESS I IC.#(REQUIRED}: <br /> s _ <br /> PRIMARY CONTACT: L7 OWNER IqCONTRACTOR 171 OTHER(Please Specify) <br /> CONTACT NAME: CONTACT PHONE: `I <br /> �— CONTACT EMAIL: - <br /> C <br /> AGREEMENT I hereby certify that 1 have read and examined is application and know the same be true, <br /> correct. All provisions of taws and ordinances governing this <br /> type of work ' mpleted whetherhave cffied 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 <br /> local law mating c truction or the performance of construction. That i am authorised by the owner of this property to perform the work for which CU of Everett official on is de and J <br /> Use On <br /> comp) ifh the State Conf ctors Law 18.27 RCW and 296.200 WAC. PERMIT# <br /> n thorizedA nt5ignature <br /> Da (Revised 1/11/2019) Page 1-Application <br />