|
HCTRCAL PERMIT AP . U I
<br /> CITY OF EVERETT PERMIT SERVICES
<br /> .71i3200 CEDAR STREET,EVERETT,WA 98201
<br /> (P)425 257 8810 I FAX�' 4255257 8885}7 1(E)everetteps@everettwa.gov gov 1 wwweverettwa.gov/permits
<br /> ROCIZWKRNMIERSM .t z - u ROJEC I I 6l�COO CIIOSSMg y' , . .. .;IIN .Y. 3.,`u.. ,'? =n'..:.. �.... .:
<br /> PROJECT ADDRESS: \BOO.- J 'j -(..' ,AJ tl 36L{ (BUILDING AREA: sq ft
<br /> PROJECT TYPE: 0 NEW CONSTRUCTION 0 ADDITION Il TENANT IMPROVMENT 0 REMODEL
<br /> BUILDING USE: 0 SFR 0 TOWNHOUSE 0 DUPLEX 0 ADU 0 MULTI-FAMILY #OF UNITS: AP3COMMERCIAL
<br /> Oy EECyATVNIINg RAqfONFV R€P 'NPORf L
<br /> w
<br /> CONTRACT PRICE OF WO' :
<br /> $ 1 t S-6" (ASSOCIATED BUILDING PERMIT#(if applicable):
<br /> DESCRIBE SCOPE OF ORK:� , 6, \ Nit.,W " �tAA .P.-c K '
<br /> THIS INSTALLATION INCLUDES THE FOLLOWING SCOPE: (SELECT ALL THAT APPLY)
<br /> LINE VOLTAGE WORK? D NO DYES-Select Scope:0 Service 0 Feeder 0 Circuits-#: 0 Complete Re-wire
<br /> LOW VOLTAGE WORK? 0 NO 0 YES-#of Devices:
<br /> SELECT SCOPE(REQUIRED):
<br /> 0 Data 0 Intercom 0 Thermostat 0 Audio *0 Secure Access 0 Security System
<br /> 0 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 /> rwif
<br /> ther(List All):
<br /> � rr 1-� � � ¢is`w x q'� t � 1 z,� a`���t���.iu...�w� `~``.�• �s�Sa i�r���s;a� a,� .�����'r��- .�:
<br /> r Y' - ..g� t �S i& g. `'.n,4., -,.,_xisYV gis .�9Ee ,� �....rF:zt,q'�i�y .",?:-�i ..,
<br /> IS THIS PERMIT EDUCATION, "W
<br /> INSTITUTIONAL,HEALTH AND/OR PERSONAL CARE FACILITIES: V d YES—See Below&Pg.2
<br /> ® 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
<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 YOU OWNER PERFORMING WORK AS THE CONTRACTOR WITHOUT ELECTRICAL LICENSURE: DYES-See Below&Pg.3
<br /> ® 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
<br /> requirement
<br /> ECOS.wNMmC >.vrI NORMA ONIS ISr w0" .
<br /> *
<br /> ce
<br /> OWNER NAME: ,r,�
<br /> v , ,. '1 c- TENANT BUSINESS NAME(If Commercial): \--Wor ' �A_ ,r
<br /> OWNER MAILING ADDRESS: STREET lc-09.'" ,-3Y_ tiQ le/ - Oita l t int
<br /> CITY STATE ZIP
<br /> OWNER PHONE: [OWNER EMAIL:
<br /> CONTRACTOR NAME: S(.et— h Y'_I-Gc�4- t- i � y
<br /> CITY CONTRACTOR ADDRESS: STREET Q,((, 9j? o el- ti�� `2
<br /> STATE 0.141 IP �) )J '
<br /> CONTRACTOR PHONE:"2..kr3 d ____JC4TRACTO- MAIL:
<br /> `
<br /> CONTRACTOR LIC.#(REQUIR=,): .`t'�^ I r elk ITY OF EVERETT BUSINESS LIC.#(REQUIRED)• 95 ,m r/5mm ww„
<br /> 4..44.�. _..4, . ,4,• ,.. 4,4a, ...u.4,. . .4,, ..,
<br /> PRIMARY CONTACT: D OWNER i CONTRACTOR ❑OT " (Please Specify)
<br /> CONTACT NAME: CONTACT PHONE: •Z,s -3 (4D .iaaf LI
<br /> „
<br /> CONTACT EMAIL:
<br /> AGREEMENT:I hereby certify that 1 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 regulating constru 'on or the performance of construction. That/am authorized by the owner of this property to perform the work
<br /> ty for
<br /> r which
<br /> Official Use made and/
<br /> comply with th ate Co tors Law 18.27 RCW and 296.200 WAC. CiPERMIT#:
<br /> ------ ( '. 5 E \c\.0 , -- U , 4
<br /> Owner/ orized Agent Signature Date
<br /> (Revised 1/11/2019) Page 1-Application
<br />
|