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<br /> Mt ELECTRICAL PERMIT APPLIC ION;"!"--'-- "----g
<br /> CITY OF EVERETT PERMIT SERVICES
<br /> OW
<br /> 3200 CEDAR STREET,EVERETT,WA 98201
<br /> (P)425-257-8810 I FAX 425-257-8857 I(E)everetteps@everettwa.gov I www.everettwa.gov/permits
<br /> Aliap �gyy��a> 5�y ��. ,�"> >Via§a� �� I��e���.-�m � �v i��� .�
<br /> �u t a '- 1 '�r Sct,'`7'.i n�� "`P�I($s�ECoT- E Nro _.. O �� `k c1.r t,?.�?' - ,_�,r�e-...�,:ri
<br /> PROJECT ADDRESS: S (% 1 ')cry &Lip (BUILDING AREA: sq ft
<br /> PROJECT TYPE: 0 NEW CONSTRUCTION DE ADDITION TENANT IMPROVMENT 0 REMODEL
<br /> BUILDING USE: ErSFR 0 TOWNHOUSE 0 DUPLEX 0 ADU 0 MULTI FAMILY #OF UNITS: COMMERCIAL
<br /> ELEC ,RIC L'�011141 }lTION letwoRM CTIQIN� aEs oti ,0 v.,.. r.� k. ..� __ .. .. ..r ..
<br /> CONTRACT PRICE OF WORK:$ S !ASSOCIATED BUILDING PERMIT#(if applicable):
<br /> DESCRIBE SCOPE OF WORK: Nem, Gv.* G< -
<br /> THIS INSTALLATION INCLUDES THE FOLLOWING SCOPE: (SELECT ALL THAT APPLY)
<br /> LINE VOLTAGE WORK? E6/J NO OYES-Select Scope:0 Service 0 Feeder 0 Circuits-#: S- 0 Complete Re-wire
<br /> LOW VOLTAGE WORK? EINO 0 YES-#of Devices:
<br /> SELECT SCOPE(REQUIRED):
<br /> 0 Data 0 Intercom 0 Thermostat 0 Audio 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 /> 0 Other(List All):
<br /> nitai a i a c a k ... ., :Mir.,. w ? , ... Magna _.. ..
<br /> IS THIS PE MIT EDUCATION,INSTITUTIONAL,HEALTH AND/OR PERSONAL CARE FACILITIES: I NO Li 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 AN OWNER PERFORMING WORK AS THE CONTRACTOR WITHOUT ELECTRICAL LICENSURE: Or10 OYES-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 requirement
<br /> i e.,..x \ 'v y AS4 T zd,S x.,ra,v...a>. -a Im'.'~< _",>•x ` Wx'W�-��^?�, > 1r->..:"�:..
<br /> d�5�� �'lv �^ t+. ,e�. %fi "�� �����3 �5•.h:, s,w"'.Y�.<��C"��� ..,n..<.... ;.,...i'.H ..
<br /> tt ���s�,L,r a�'.i,�. s�'\..es$S,�;>??,��1l.•.�.,�`� �.>...•�...c�,�, � �,� :�n� .w ..,,.,.
<br /> OWNER NAME: 5lte PhC 1 F--►f.KL°ip Ke/ TENANT BUSINESS NAME(If Commercial):
<br /> OWNER MAILING ADDRESS: STREET 6 5 0 6 7veit y ✓(U
<br /> CITY eFh/el'e STATE VA- ZIP ��Z 05
<br /> OWNER PHONE: CLS rj 57 (OWNER EMAI J C k-�a.o ' tt
<br /> I ,C
<br /> CONTRACTOR NAME: nit/ jS/CC.1-r,�( * 1-1
<br /> r
<br /> /10/11 1441 Ave .- 3 '4 t Ppb T 0(
<br /> CONTRACTOR ADDRESS: STREET `� L ��/y�
<br /> CITY�l'.VCJ -#T STATE �'" /1 ZIP `i`� _
<br /> (CONTRACTOR EMAIL: e4 Lt f' Gve45.,/1 d. �e '^`t 'I .CCM"
<br /> CONTRACTOR PHONE: �7i S .�� �1SZL
<br /> CONTRACTOR LIC.#(REQU ED): N V2 7 L 'L CITY OF EVERETT BUSINESS LIC.#(REQUIRED): 19
<br /> PRIMARY CONTACT: OWNER 0 CONTRACTOR 0 OTHER(Please Specify)
<br /> CONTACT NAME: 516....,,Pkie.A CONTACT PHONE: U 4J-S S GO 5 ,
<br /> CONTACT EMAIL ie...j;c.( 0_,(AO I ,Itl 'M
<br /> AGREEMENT:I hereby certify that!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 construction or the performance of construction. That I am authorized by the owner of this property to perform the C r for
<br /> Ewhictt Officiation
<br /> c atli n Use Onis and!
<br /> comply with the State Contractors Law 18.27 RCW and 296.200 WAC. ty PERMIT#:
<br /> red \AO\-'IP.O
<br /> 1
<br /> uth I Agent Signature ate
<br /> (Revised 1/11/2019) Page 1-Application
<br /> ., .
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