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ELECTRICAL PERMIT APPLIGA k ION <br /> CITY OF EVERETT PERMIT SERVICES <br /> 3200 CEDAR STREET,EVERETT,WA 98201 <br /> (P)425-257-8810 I FAX 425-257-8857 E everette s everettwa gov I www.everettwa.gov/Permits <br /> p /r I Oma �p �p @ <br /> ttifgEMVNSMCSM <br /> r-i <br /> - ..._...� .,>„..,,. aur..... . - - ' <br /> PROJECT ADDRESS: 22,1 W C1'Yu2 .6 (BUILDING AREA: sq ft <br /> PROJECT TYPE: 0 NEW CONSTRUCTION 0 ADDITION 114ENANT IMPROVMENT 0 REMODEL <br /> BUILDING USE: 0 SFR 0 TOWNHOUSE 0 DUPLEX 0 ADU 0 MULTI FAMILY #OF UNITS: 0 COMMERCIAL <br /> ASTAMMELEq' R C,ALS_APPL1 AT[O `INFORMATION.& DESSR1t TONIAPIRCASIUMWOR <br /> CONTRACT PRICE OF WORK:$q.( er) (ASSOCIATED BUILDING PERMIT#(if applicable): <br /> DESCRIBE SCOPE OF WORK: 0.F C• L tiftoO L- <br /> EXp - `V6K-C 11E1 -Pt,\JcC = 0 J x D - 1O <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-#: 5 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 /> 0 Other(List All):tteRAMy <br /> ti x� Z �s .;... .B cOMP!ANWMrMM s "``'rs^aeO . : v:-.?nm'h <br /> LEt <br /> IS THIS PERMIT EDUCATION,INSTITUTIONAL,HEALTH AND/OR PERSONAL CARE FACILITIES: ' NO 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 AN OWNER PERFORMING WORK AS THE CONTRACTOR WITHOUT ELECTRICAL LICENSURE: NO ®YES-See Below&Pg.3 <br /> rl 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 this licensing/certification requirement <br /> t IShl� z} -.A4X�'+�`K x}„..:T IVIS x CONIIIA�V �IINPO i � <br /> ,�._ <.MNS -.. SSS... ._SPc ...x M..<,>.. <br /> OWNER NAME: y TENANT BUSINESS NAME(If Commercial): <br /> OWNER MAILING ADDRESS: STREET ej ACI-11k IX<'E N� �y <br /> [ <br /> STATE LAI I,"1(" ZIP -�yI(J1� <br /> CITY �('7'�i,Y.�1\L/li <br /> OWNER PHONE: OWNER EMAIL: - <br /> CONTRACTOR NAME: MitC.0 <br /> CONTRACTOR ADDRESS: STREET IO ��X Ifs <br /> ..STATE I/`}' <br /> CITY E17M p�D''� ZIP 98020 < <br /> CONTRACTOR PHONE:/0 vs", /poll CONTRACTOR EMAIL: q <br /> CONTRACTOR LIC.#(REQUIRED): ! tY Z CITY OF EVERETT BUSINESS LIC.#(REQUIRED): OSz- s <br /> PRIMARY CONTACT: 0 OWNER `CONTRACTOR 0 OTHER(Please Specify) <br /> CONTACT NAME: CONTACT PHONE: Lr 7 .215 20'7 <br /> 2 <br /> ISM. K5L3 CONTACT EMAIL: -b LGLf p,J t^ p�;�"�- rr -maze_c w'- <br /> AGREEMENT:I her by certify that I have read and examined this application and know the same to be due 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 work of Efor which Opic licaati ion Use Only ye is and I <br /> comply with the Contractors Law 18.27 RCW and 296.200 WAC. PERMIT#: <br /> " E Vlo ( - lSO <br /> Owner/Authorized 41.ignature Date (Revised 1/11/2019) Page 1-Application <br />