8102 EVERGREEN WAY EVERETT 4 CORNERS - BLDG D 2025-08-06

a.ECTRICAL PERMIT APPI IrATION CITY OF EVERETT PERMIT SERVI( EVERETT 3200 CEDAR STREET, EVERETT,WA 98201 WASHINGTON (P)425-257-8810 I(E)PermitServices@everettwa.gov I vvww.everettwa.gov/permits PROJECT SITE INFORMATION PROJECT ADDRESS: `0 \itAl\t/VA, ilICk,t/t BUILDING AREA: sq ft PROJECT TYPE: c21NEW CONSTRUCTION ❑ADDITION ❑TENANT IMPROVMENT ❑REMODEL BUILDING USE: ❑SFR LI TOWNHOUSE ❑DUPLEX ❑ADU ❑MULTI-FAMILY-#OF UNITS: 0 COMMERCIAL ELECTRICAL APPLICATION INFORMATION & DESCRIPTIQN OF WORK CONTRACT PRICE OF WORK: $ \(200 ASSOCIATED BUILDING PERMIT#(if applicable): DESCRIBE SCOPE OF WORK: 4r6A0ii,vvic , Q. Co,r\-\v \ kNJ\v\\ r" o'`' MVvi l,c) S 1/1Ste ✓k. 'fS.\11\, 0;4 [ \\IAC THIS INSTALLATION INCLUDES THE FOLLOWING SCOPE: (SELECT ALL THAT APPLY) • LINE VOLTAGE WORK? t5D,NO CI YES-Select Scope: ElService ❑Feeder ❑ Circuits-#: ElComplete Re-wire LOW VOLTAGE WORK? D NO EYES-#of Devices: SELECT SCOPE(REQUIRED): ❑Data ❑Intercom 0 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 U 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:'RNO OYES-See Below&Pg. 2 Pursuant to RCW 19.28.261, property owners and leaseholders cann'ot 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:OV`Y' C,04.VA a V&L4C ( 1 LL TENANT BUSINESS NAME (If Commercial):{'t7f,tl" C i 'WS i OWNER MAILING ADDRESS: STREET `//`ny Nit J�{ VA 7 yZ 1 W CITY & 'L STATE T ZIP OWNER PHONE: 5SI1 OWNER EMAIL: CONTRACTOR NAME: c CUM Mil. (Al tt--CONTRACTOR ADDRESS: STREET IE ` ,A ci- C .S - rrJ, g� �c1,�,\,CITY , �( STATE wA ziP 0p 'j-?-75 CONTRACTOR PHONE:3 3)`11% . 60 CONTRACTOR EMAIL: cc�tP utto q l�" Stivtariativiq CONTRACTOR LIC.#(REQUIRED): , r` 'At1(- CITY OF EVERETT BUSINESS LIC.#(REQUIRED): (J4 11 PRIMARY CONTACT: DOWNER C CONTRACTOR El OTHER(Please Specify) CONTACT NAME: CONTACT PHONE: '' ;:2-2„, CONTACT EMAIL: GNa, 6 cmg\pANIA (y� 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 I comply with the State Contractor Law 18.27 RCW and 296.200 WAC. City of Everett Official Use Only PERMIT#: /940 _9- E s o l 01 Owner/Authorize Agent Signature Date (Revised 4/5/2022) Page 1-Application