11415 19TH AVE SE AMERICAN FAMILY INSURANCE 2017-09-25

RECTRICAL PERMIT APPICATION CITY OF EVERETT PERMIT SERVICES 3200 CEDAR STREET, EVERETT, WA 98201 (P)425-257-8810 1 FAX 425-257-8857 1 (E) everetteps@everettwa.gov I www.everettwa.gov/permits PROJECT SITE INFORMATION PROJECT ADDRESS: I C( h C_ 4?- Oe 10 D BUILDING AREA(if residential, new construction, remodel, or addition) SF BUILDING TYPE: ❑ SFR-DETACHED ❑ SFR-ATTACHED ❑ DUPLEX ❑ MULTI-FAMILY-#OF UNITS: ❑ COMMERCIAL USE OF BUILDING: ELECTRICAL APPLICATION INFORMATION CONTRACT PRICE OF WORK: $ _� 0 0, b NUMBER OF DEVICES if low voltage): FIRE ALARM? ❑YES ❑ NO ASSOCIATED BUILDING PERMIT#(if applicable): DESCRIPTION OF WORK: V(11 Gly ( ✓1 CONTACT INFORMATION OWNER NAME: 7 ( TENANT NAME(If Commercial): f OWNER MAILING ADDRESS: STREET 125b1 f3 f f— K ie Ior� CITY N, ' v STATE ZIP OWNER PHONE: OWNER EMAIL: CONTRACTOR NAME: -I CONTRACTOR ADDRESS: STREET Q \ S. CITY STATE r l ZIP CONTRACTOR PHONE: Voi— I' CTOR EMAIL: I ��(V1 i CONTRACTOR LIC.#(REQUIRED): CITY OF EVERETT BUSINESS LIC.#(REQUIRED):Z�SO89 PRIMARY CONTACT: ❑ OWNER CONTRACTOR ❑OTHER(Please Specify) CONTACT NAME: I CONTACT PHONE: Sl�t111 e V1(\� u (5 CONTACT EMAIL: AGREEMENT.'1 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 State Contractors Law 18.27 RCW and 296.200 WAC. City of Everett Official Use Only PERMIT# E Owner/Authorized Age Signature Date (Revised 9/23/2016)