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® • ELECTRICAL PERMIT APPLICATION EVERETT CITY OF EVERETT PERMIT SERVICES 3200 CEDAR STREET,EVERETT,WA 98201 WASHINGTON (P)425-257-8810 I FAX 425-257-8857 I(E)everetteps@everettwa.gov I www.everettwa.gov/permits PROJECT SITE INFORMATION C PROJECT ADDRESS: 89 p�1 -1 ,"t/`e 3 BUILDING AREA: sq ft PROJECT TYPE: ❑ NEW CONSTRUCTION ❑ IN/ ADDITION ❑TENANT IMPROVMENT L�REMODEL BUILDING USE: X.SFR ❑ TOWNHOUSE ❑ DUPLEX ❑ADU ❑ MULTI-FAMILY-#OF UNITS: ❑ COMMERCIAL ELECTRICAL APPLICATION INFORMATION.& DESCRIPTION OF WORK CONTRACT PRICE OF WORK:$ 16 V ASSOCIATED BUILDING PERMIT#(if applicable): DESCRIBE SCOPE OF WORK: � \C# c ,\siJ'\ YfdQ THIS INSTALLATION INCLUDES THE FOLLO ING SCOPE: (SELECT ALL THAT APPLY) LINE VOLTAGE WORK? NO k YES-Select Scope: ❑ Service ❑ Feeder Circuits-#: D� ❑ Complete Re-wire LOW VOLTAGE WORK? 7f,.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): CODE COMPLIANCE IS THIS PERMIT EDUCATION, INSTITUTIONAL,HEALTH AND/OR PERSONAL CARE FACILITIES: ❑ NO ❑ 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: ❑NO EYES-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 rt «a p �.� OWNER NAME:qad 4 Jess � `�- TENANT BUSINESS NAME(If Commercial): OWNER MAILING ADDRESS t9TREET. /Iry\/ r SE /J�y CITY ,t�V l� �-+t,.}C STATE INPr- ZIP c of 2.0� OWNER PHONE: a� 3 �1 U/ OWNER EMAIL: a 1 1-C e ,gtyvw fC)� CONTRACTOR NAME: O J �-P� V P�^s1 Cai n_t 1 l e �1 CONTRACTOR ADDRESS: STREET `� CITY STATE ZIP CONTRACTOR PHONE: CONTRACTOR EMAIL: CONTRACTOR LIC.#(REQUIRED): CITY OF EVERETT BUSINESS LIC.#(REQUIRED): PRIMARY CONTACT: &IOWNER ❑CONTRACTOR ❑OTHER(Please Specify) �,9� jACS CONTACT NAME: CONTACT PHONE:I06-3 (..0)4(.0 /L.06--3crq o`ia5 es \ CONTACT EMAIL: '1 oqiymi am 4 [/ I . &j 4tal.i.am AGREEMENT:I hereby certify that I have read and examined this application and know e same t.ia true aid correct. All provisions df I ws a ordinances govg 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 property to perform the work for which application is made and I comp! with the State Contractors Law 18.27 RCW and 296.200 WAC. City of Everett Official Use Only PERMIT#: LI- ❑ga EZ2A2 -oo2.: O rter/Authorized Agent Signa u e Date (Revised 1/11/2019) Page 1-Application