2110 BROADWAY STE C 2025-09-09 - Laserfiche WebLink

ELECTRICAL PERMIT APPLICATION CITY OF EVERETT PERMIT SERVICES EVERETT 3200 CEDAR STREET,EVERETT,WA 98201 WASHINGTON (P)425-267-8810 1(E)PermitServices@eveTettwa.gov I www.everettwa.gov/pormits PROJECT ADDRESS: -�9/z'o BUILDING AREA: sq ft PROJECT TYPE: 11 NEW CONSTRUCTION El ADDITI 11 TENANT IMPROVMENT 11 REMODEL BUILDING USE: 0 SFR El TOWNHOUSE 11 DUPLEX 13 ADU 11 MULTI-FAMILY-#OF UNITS: ❑ COMMERCIAL "'OF VORK WAT VO RICALAFT 30K. NPORMAT N CONTRACT PRICE OF WORK:$ 1ASSOCIATED BUILDING PERMIT#(if applicable): DESCRIBE SCOPE OF WORK: v-k' THIS INSTALLATION INCLUDES THE FOLLOWING SCOPE: (SELECT ALL THAT APPLY) LINE VOLTAGE WORK? 11 NO ff_YES-Select Scope: 13Service 1:1 Feeder 11 Circuits-M=i4== 11 Complete Re-wire LOW VOLTAGE WORK? 11 NO 11 YES-#of Devices: SELECT SCOPE(REQUIRED): 0 Data 1:1 Intercom 11 Thermostat 13Audio ElSecure Access 11 Security System 1:1 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): C IGOMIK IS THIS PERMIT EDUCATION, INSTITUTIONAL,HEALTH AND/OR PERSONAL CARE FACILITIES: LJ NO EJ YES See Below&Pg.2 El 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:WO DYES-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. N 7"'CONTACT OWNER NAME: TENANT BUSINESS NAME(if Commercial): V OWNER MAILING ADDRESS: STREET 0 f- - _ , viA 7-V e C/ CITY STATE 912-01 ZIP OWNER PHONE: 1OWNER EMAIL: CONTRACTOR NAME: CONTRACTOR ADDRESS: STREET ju A AAQ� jj� AVK U J Lu" CITY STATE ZIP U U CONTRACTOR PHONE: 1CONTRACTOR EMAIL: rily OF EVERET CONTRACTOR LIC.#(REQUIRED): ICITY OF EVERETT BUSINESS 1_16T M_ Vf9&C$erv1ces PRIMARY CONTACT: 0 OWNER El CONTRACTOR El OTHER(Please Specify) CONTACT NAME: CONTACT PHONE: CONTACT EMAIL: 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 Contractors Law 18.27 RCW and 296.200 WAC. City of Everett Official Use Only I PERMIT M ti5) F 2504- 00 Kner/Auithorized Agent Signature Date (Revised 41512022) Page 1-Application