2112 LOMBARD AVE 2019-03-28 - Laserfiche WebLink

ELECTRICAL PERMIIT APPLfiCATIION CITY OF EVERETT PERMIT SERVICES 3200 CEDAR STREET,EVERETT,WA 98201 (P)425-257-8810 i FAX 425-257-8857 1(E)everetteps@everettwa.gov I wwvv.everettwa.gov/permitsIPrT� _�_ ? t' S `° �� © Lill ECG��? _ PROJECT ADDRESS: 2•a t 2 LV-v1 � i Ni‘:-. 'BUILDING AREA: sq ft PROJECT TYPE: 0 NEW CONSTRUCTION 0 ADDITION 0 TENANT IMPROVMENT -REMODEL j] COMMERCIAL BUILDING USE: FRS0 TOWNHOUSE 0 DUPLEX 0 ADU 0 MULTI FAMILY-#OF UNITS: ELECTRICAL APPLEGA`I E 191 +@utr iAT I 'IES-G IP tON OF WOR 'CONTRACT PRICE OF WORK: $ ASSOCIATED BUILDING PERMIT#(if applicable): ,_;.v, ).. J ,A., 'DESCRIBE SCOPE OF WORK: vhS\n CJ.nnLA-•°.r t e\Gc 1►IIS % •' t 4 s4 PNA- L O vr_S cneir•-c:Q' re. S,e. cD\PO-AM in/ r..(730-0 - P✓t- Cts � S Cif, �-- A 4.3 C1v -C'la4L % 12nrirOw Ity.NA– PeOwD 5 V\i` `u5 THIS INSTALLATION INCLUDES THE FOLLOWING SCOPE: (SELECT ALL THAT APPLY) 1 LINE VOLTAGE WORK? 0 NO 0 YES-Select Scope: 0 Service 0 Feeder 0 Circuits-#: 0 Complete Re-wire LOW VOLTAGE WORK? 0 NO 0 YES-#of Devices: SELECT SCOPE(REQUIRED) 0 Data 0 Intercom 0 Thermostat 0 Audio iii Secure Access C Security System 0 Fire Alarm-Installations under this permit only include electrical wiring rough-in of the system.An additional Fire Alarm Permit is required for review of device location and installation approval. 0 Other(List All): ----- CODECOMP UANC>h • -• ' "' "" C� III --See Below&Pg.2 IS THIS PERMIT EDUCATION,INSTITUTIONAL,HEALTH AND/OR PERSONAL CARE FACILITIES: NO 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 of this application(see next page),AND Plan Review is NOT required because I meet all of the following sub sections that do not See Page 2 require Plan Review. ;ARE YOU AN OWNER PERFORMING WORK AS THE CONTRACTOR WITHOUT ELECTRICAL LICENSURE: ANO IIIKS-See Below&Pg. 3 Pursuant to RCW 19.28.261,property owners and leaseholders cannot perform electrical work on buildings for rent, sale,or lease I 6._u_ without the proper electrical licensing and certification,or exemption. By checking this box, I am stating that I have completed and 1 See Page 3 signed the AFFIDAVIT on page 3 of this application to receive an exemption from this licensing/certification requirement. . CONTACT INFORMATION ..__ , OWNER NAME: Oil P.(1, 'A-1,04- TENANT BUSINESS NAME(If Commercial): 2\k L kt,„"b int . 1 OWNER MAILING ADDRESS: sTREEr ��2.0ex../0-1- STATE ZIP CIN OWNER PHONE: (LI SS�1 OWNER EMAIL: . •"E----"*""?.- G.-,4 5� 4, - _(. Z ��7 g E----"*""?.-E----"*""?.- 1CONTRACTOR NAME: t'v-i CONTRACTOR ADDRESS: STREET CITY STATE ZIP {CONTRACTOR PHONE: 'CONTRACTOR EMAIL: CONTRACTOR LIC.#(REQUIRED): CITY OF EVERETT BUSINESS LIC.#(REQUIRED): PRIMARY CONTACT: 112-OWNER 0 CONTRACTOR 0 OTHER(Please Specify) 'CONTACT NAME: CONTACT PHONE: l LS) Li)vesSti Ciii 0 f'"'t.- CONTACT EMAIL: 9,,b.iy S1E.r4P'gR't ,5w")ci. .('• "i- . 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 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 I City of Everett Official Use Only comply with the State Contractors Law 18.27 RCW and 296.200 WAC. PERMIT#: C— k -''1/4---- VLI • E ',t! ( q02 -O • n Owner/Authorized Agent Signature Date (Revised 1/11/2019) Page 1-Application