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ELECTRICAL PERMIT APPLICATION CITY OF EVERETT PERMIT SERVICES EVERETT 3200 CEDAR STREET,EVERETT,WA 98201 WASHINGTON (P)425-257-8810 1(E)PermltServices@evereltwa.gov I vnrrw.everettwa.gov/permits n'.PROJECT.SITE INFORMATION, [` PROJECT ADDRESS: i �Q�'Oy\ t`j U G BUILDING AREA: ylX7� sq ft PROJECT TYPE: ❑ NEW<6NSTRUCTION ❑ADDITION ❑ TENANT IMPROVMENT EfREMODEL BUILDING USE: VKSFR ❑TOWNHOUSE ❑ DUPLEX ❑ADU ❑ MULTI-FAMILY-#OF UNITS: ❑ COMMERCIAL EL9CTR APP. . G INFORMAT.ION $�'DESCRIPTION iOF WORK CONTRACT PRICE OF MAR.$ ASSOCIATED BUILDING PERMIT#(if applicable): 31 0 DESCRIBE SCOPE OF ••A) %y ',. THIS INSTALLATION INCLUDES THE FOLL ING SCOPE: (SELECT ALL THAT APPLY) LINE VOLTAGE WORK? ❑ NO YES-Select Scope: ❑ Service ❑ Feeder Circuits-M FroComplete Re-wire LOW VOLTAGE WORK? ❑ NO 41 YES-#of Devices: SELECT SCOPE(REQUIRED): ❑ Data ❑ Intercom OoThermostat ❑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): clout bed s 0,) CODE_COMPLIANCE ' IS THIS PERMIT EDUCATION, INSTITUTIONAL,HEALTH AND/OR PERSONAL CARE FACILITIES: Lff NO L1 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 0YES-See Below&Pg.3 E] 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. r CONTACT INFORMATION ' c OWNER NAME: + AIJ ,M TENANT BUSINESS NAME If Commercial): OWNER MAILING ADDRESS: STREET (01 1 `b0►) 91 �) CITY 00f STATE L ZIP O2-DI OWNER PHONE: OWNER EMAIL: CONTRACTOR NAME: CONTRACTOR ADDRESS: STREET 14 Al /� CITY STATE ZIP 102 CONTRACTOR PHONE: CONTRACTOR EMAIL: CITY OF CONTRACTOR LIC.#(REQUIRED): CITY OF EVERETT BUSINESS LIC.#(REQUI (Tit Sery PRIMARY CONTACT: OWNER ❑CONTRACTOR ❑OTHER(Please Specify) CONTACT NAME: CONTACT PHONE: 2S 34 CONTACT EMAIL: '�IV44 q-e 24 CO) ' " . roo/ , AGREEMENT.I hereby certify that I have read and examined this application and know the same to be true and correct. All provisions of laws and ordinances 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 property to perform the work for which application is made and/ comply with the Stale Contractors Law 18.27 RCW and 296.200 WAC. City of Everett Official Use Only PERMIT#: 2 -n 123 E 2JA0 c 03 Owner/Authorized Agent Signature Date (Revised 41512022) Page 1-Application