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MCTRICAL PERMIT APPLIION
<br /> CITY OF EVERETT PERMIT SERVICES
<br /> �� 3200 CEDAR STREET,EVERETT,WA 98201
<br /> (P)425-257-8810 I FAX 425-257-8857 1(E)everetteps@everettwa.gov I www.everettwa.gov/permits
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<br /> PROJECT ADDRESS: j 00 // a A.-VC/ BUILDING AREA: 4'--- sq ft
<br /> PROJECT TYPE: 0 NEW CONSTRUCTION 0 ADDITION in TENANT IMPROVMENT 0 REMODEL
<br /> BUILDING USE: 0 SFR 0 TOWNHOUSE 0 DUPLEX 0 ADU 0 MULTI-FAMILY-#
<br /> _,. OF UN
<br /> ITS: Igi COMMERCIAL
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<br /> CONTRACT PRICE OF WORK:$ 7/ 7‘-
<br /> 6--(2 ASSOCIATED BUILDING PERMIT#(if applicable):
<br /> DESCRIBE SCOPE OF WORK: Le 1) 1Z-5-71-72-0 *rt.- -POLS v11 Z '$
<br /> g-A2iVIO 4-1/x= , /7-1x
<br /> THIS INSTALLATION INCLUDES THE FOLLOWING SCOPE: (SELECT ALL THAT APPLY)
<br /> LINE VOLTAGE WORK? 0 NO YES-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): 0 Data 0 Intercom 0 Thermostat 0 Audio .0 Secure Access 0 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):
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<br /> IS THIS PERMIT EDUCATION,INSTITUTIONAL,HEALTH AND/OR PERSONAL CARE FACILITIES: UNO 0 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 LICENSUREO ES-See Below&Pg.3
<br /> 0 Pursuant to RCW 19.28.261,property owners and leaseholders cannot perform electrical work on uildings or 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 /> Mare"t} �""�'^Y�,'x s 1ti .�.� �ey�1c5+:�°8=.?) h��'�x -ti w� ■ q LL '"pit wr r'3�°4� a5��"4,.
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<br /> OWNER NAME: C Q .- ] .. S TENANT BUSINESS NAME` Coal): t VQM {e, 1—k
<br /> mmerci
<br /> OWNER MAILING ADDRESS: STREET E.- G, Pi j c/ b((If I'a Q �y
<br /> CITY C C /7 STATE f 4J/7 ZIP g 2a
<br /> OWNER PHONE: — (?...),35-4.-- OWNER EMAIL: :. 0,, e,,vee, A 111.A9G1, 40../
<br /> CONTRACTOR NAME: 0tAi+'lam
<br /> CONTRACTOR ADDRESS: STREET
<br /> CITY STATE ZIP
<br /> CONTRACTOR PHONE: • 'CONTRACTOR EMAIL:
<br /> CONTRACTOR LIC.#(REQUIRED): CITY OF EVERETT BUSINESS LIC.#(REQUIRED):
<br /> PRIMARY CONTACT: OWNER ❑CONTRACTOR ❑OTHER(Please Specify)
<br /> CONTACT NAME: CONTACT PHONE: .1)41,---
<br /> iS—.e9g -4 0 79
<br /> D A�R(`�'�ir6..c A ke �- CONTACT EMAIL: Lt e,561i �,. 1v/4., q 6
<br /> AGREEMENT•I hereby certify that I have read and examined this application and know the salve to be true and correct. All provisions of laws and ordinances overning 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 work for which application is made and I
<br /> comply with the State Contractors Law 18.27 RCW and 296.200 WAC. City of Everett Official Use Only
<br /> PERMIT#:
<br /> ,i� 44 �` E '(.16907 - a,
<br /> 0 r/Authori d Agent Signature Date (Revised 1/11/2019) .Application
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