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ini WoECTRICAL PERMIT APPL „ \TION
<br /> EVERETT CITY OF EVERETT PERMIT SERVICz;;
<br /> 3200 CEDAR STREET,EVERETT,WA 98201
<br /> WASHINGTON (P)425-257-8810 1 FAX 425-257-8857 1(E)everetteps@everettwa.gov I www.everettwa.gov/permits
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<br /> I�1` �: PROJECT SITE 1INFORMATION -
<br /> PROJECT ADDRESS: Pg ID eikr&-+1 A/6, BUILDING AREA: sq ft
<br /> PROJECT TYPE: ❑ NEW CONSTRUCTION ❑ADDITION N.TENANT IMPROVMENT ❑ REMODEL
<br /> BUILDING USE: ❑SFR CITOWNHOUSE ❑ DUPLEX El ADU 111MULTI-FAMILY-#OF UNITS: R.1 COMMERCIAL
<br /> .. EC's: ., AL P $ATIo ,_INFORMATION & OES R1PTI.. i::OF WORK •','_
<br /> CONTRACT PRICE OF WORK: $ , 000 ASSOCIATED BUILDING PERMIT#(if applicable): I
<br /> DESCRIBE SCOPE OF WORK: De,m U ,/01 elt c-i-r,I(.,q1 W;,r i 1 1-0 ,4n'v) s+ C 'fc-tr'e.-• i ''z_irl
<br /> es LA i\ V1 cid de c-1--,6 LA l c,.A a( CATS U' ,r f o Al e t.' A-T 141 /o c c-1-I 00 .
<br /> THIS INSTALLATION INCLUDES THE FOLLOWING SCOPE: (SELECT ALL THAT APPLY)
<br /> LINE VOLTAGE WORK? ❑ NO ®YES-Select Scope: ❑ Service ❑ Feeder N Circuits-#: tI ❑ Complete Re-wire I
<br /> LOW VOLTAGE WORK? ❑ NO F,1 YES-#of Devices: 3
<br /> SELECT SCOPE(REQUIRED):,E1 Data ❑ Intercom ❑ Thermostat ❑Audio ❑ Secure Access 71 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 /> _; �, OOZE COMPLIANCE°
<br /> IS THIS PERMIT EDUCATION, INSTITUTIONAL, HEALTH AND/OR PERSONAL CARE FACILITIES: NO 71 YES--See Below&Pg.2
<br /> 7By checking this box, I am stating that I have read and understand all of WAC 296-46B-90 selected 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 YOUAN OWNER PERFORMING WORK AS THE CONTRACTOR WITHOUT ELECTRICAL LICENSURE: ®NO EYES-See Below&Pg.3
<br /> l
<br /> l Pursuant to RCW 19.28.261, property owners and leaseholders cannot perform electrical work on buildings for rent,sale, 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 licensing/certification requirement.
<br /> 4,,,w,,,--4w,, 7'42,. 1. :- '' iPg5, .. / ONA l NF0 ATI t4 _> " 2a,,
<br /> OWNER NAME: (c)/(..4 AA C)41 1304 .
<br /> TENANT BUSINESS NAME(If Commercial): Coilkr,brc, en,„ k/
<br /> OWNER MAILING ADDRESS: STREET /1 O EtderL:++ AA_ 'r ' _---s,. ' "4.-- 4
<br /> CITY Vert-41 STATE WA- ZIP 1 CJ2-0l
<br /> OWNER PHONE: OWNER EMAIL:
<br /> CONTRACTOR NAME: Uct i ey elInw44 a n.I, avt pt E I?c f r;L
<br /> CONTRACTOR ADDRESS: STREET 9(Q W. cot SI , /� �C
<br /> CITY S 1.44/11,1.44/11,c� STATE �! ' ZIP q6 2. -( s
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<br /> CONTRACTOR PHONE: 3(F 0-q"l IS-%3( CONTRACTOR EMAIL: 0-4-ic-e z Jh:llzr re . (0.4A.
<br /> CONTRACTOR LIC.#(REQUIRED): EC V 1C PJ),=1,LT CITY OF EVERETT BUSINESS LIC.#(REQUIRED):
<br /> PRIMARY CONTACT: ❑OWNER CONTRACTOR ❑OTHER(Please Specify)
<br /> CONTACT NAME: ba t`,;, CONTACT PHONE: Z(.0 - 46i 5-- s1-3
<br /> qaN(fel tt,;o(h. i•u..^ CONTACT EMAIL:
<br /> ckar:Ir � Val1_ty pt. ca✓A
<br /> 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
<br /> 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
<br /> local law regulati . onstruction 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
<br /> 61comply with the t.to Contractors La 18.27 RCW and 296.200 WAC. City of Everett Official Use Only
<br /> PERMIT#:
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<br /> fe- 3o- 2-c) E2DCA— lq (6
<br /> Owner/Authorized Agent Signature Date (Revised 1/11/2019) Page 1-Application
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