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I <br /> ELECTRICAL PERMIT & FIRE ALARM PERMIT APPLICATION <br /> CITY OF EVERETT PERMIT SERVICES <br /> 047T <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 /> PROJECT SITE INFORMATION� <br /> PROJECT ADDRESS: 1 3 0 1 ' Ia i4G 1)l <br /> PROJECT TYPE: 0 NEW CONSTRUCTION 0 ADDITION 0 TENANT IMPROVMENT REMODEL <br /> BUILDING USE: 14SFR 0 TOWNHOUSE 0 DUPLEX 0 ADU 0 MULTI-FAMILY-#OF UNITS: 0 COMMERCIAL <br /> BUILDING AREA: 5-00 sq ft <br /> ELECTRICAL APPLICATION INFORMATION <br /> CONTRACT PRICE OF WORK:$ f 5-00. ASSOCIATED BUILDING PERMIT#(if applicable): <br /> IS THIS LOW VOLTAGE WORK? 1NO 0 YES-#OF DEVICES: ' ' <br /> IS THIS A FIRE ALARM PERMIT? 0 NO 0 YES-Plans required for review(Both Electrical and Fire Department inspections are required) <br /> DESCRIPTION OF WORK & CODE COMPLIANCE <br /> DESCRIPTION OF WORK: i/J 5 f i9fj /9.C- f !I.2C I it Z 5- 0Nt j Sri/z L/CC F <br /> THIS SECTION APPLIES TO ALL EDUCATION,INSITUTIONAL,HEALTH AND/OR PERSONAL CARE FACILITIES: <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 /> ATTENTION OWNERS:THIS SECTION IS FOR OWNERS PERFORMING WORK AS THE CONTRACTOR WITHOUT ELECTRICAL LICENSURE: <br /> ❑ Pursuant to RCW 19.28.261,property owners and leaseholders cannot perform electrical work on buildings for rent,sale,or lease without <br /> the proper electrical licensing and certification,or exemption.By checking this box,I am stating that I have completed and signed the <br /> See Page 3 AFFIDAVIT on page 3 of this application to receive an exemption from this licensing/certification requirement. <br /> CONTACT INFORMATION <br /> OWNER NAME: 'Sv1-1J b/ ,! BUSINESS NAME(If Commercial): <br /> ((Jl'L TENANT D <br /> OWNER MAILING ADDRESS: STREET L/3 Q/ /22itCt b R 1 <br /> C) i2..if,, l ! CITY STATE Gtfil, ZIP IOZCS <br /> OWNER PHONE: L-/ L' --7`111$?qs OWNER EMAIL: <br /> CONTRACTOR NAME: C,14 L L l(14,C T4 t L f e <br /> CONTRACTOR ADDRESS: STREET/o ' O 3 o,x Z.,/85-- <br /> //t.// v <br /> CITY AiyCJO6 STATE CA) ZIP gc®36 <br /> CONTRACTOR PHONE: /Z5 / 3'S-33$ CONTRACTOR EMAIL: Cif/L!'E.LCC 1 Z'C OP"kV—o COQ( <br /> CONTRACTOR LIC #(REQUIRED) Col/ j * Q(ZQ N CITY OF EVERETT BUSINESS LIC.#(REQUIRED): <br /> �u <br /> .. .� . ._. ONTRACTOR 0OTHER Plea...,._. __ ,`. � _.�_ 4�._.. <br /> PRIMARY CONTACT: 0 OWNER XC (Please Specify) *4'0 t (Q-5 °I LII <br /> ,CONTACT NAME: CONTACT PHONE: Z o&_ f qq- Z/ 5-3 <br /> AJA (S GALL CONTACT EMAIL: GAlCL 'Ltec /erC ,1-OC a G'0„t„.( <br /> 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 <br /> 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 <br /> 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 <br /> work for which application is made and I comply with the State Contractors Law 18.27 RCW and 296.200 WAC. <br /> City of Everett Official Use Only <br /> '':-. —e_i i(z7 / (-- 6 - / i( PERMIT# <br /> -Ace5N , 6q3 <br /> 0 ner/Authorized Agent Signature Date (Revised 10/30/2018) Page 1 of 3 <br />