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ELECTRICAL PERMIT APPLICATION
<br /> (4r477- CITY OF EVERETT PERMIT SERVICES
<br /> 3200 CEDAR STREET,EVERETT,WA 98201
<br /> (P)425-257-8810 I FAX 425-257-8857 J(E)everetteps@everettwa.gov] www.everettwa.gov/permits
<br /> PROJECT SITE INFORMATION
<br /> PROJECT ADDRESS:(;;C)U,; V i Pa a;, . CA ON 9, { -,r BUILDING AREA: .-;.AcNA sq ft
<br /> PROJECT TYPE: El NEW CONSTRUCTION ❑ADDITION ❑TENANT IMPROVMENT ,REMODEL
<br /> BUILDING USE: ,.ErSFR El TOWNHOUSE El DUPLEX El ADU ❑ MULTI-FAMILY-#OF UNITS: ❑ COMMERCIAL
<br /> ELECTRICAL APPLICATION INFORMATION & DESCRIPTION OF WORK .,
<br /> CONTRACT PRICE OF WORK:$ , a4-1,(-I-N. ^ASSOCIATED BUILDING PERMIT#(if applicable):
<br /> DESCRIBE SCOPE OF WORK: J'L.N fC-), ;vi-B--Cts 'Y7t),- v,,R\t-in,, Y>�?kr^#. 1^t^rc- (,It— k. °s. 4... �— /'
<br /> (;Oa ghi,t . C hri,c.2. (--,$.1;-• d1—\a r,. t 1
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<br /> THIS INSTALLATION INCLUDES THE FOLLOWING SCOPE: (SELECT ALL THAT APPLY)
<br /> LINE VOLTAGE WORK? 2No El YES-Select Scope:❑Service El Feeder El Circuits-#: ❑Complete Re-wire
<br /> LOW VOLTAGE WORK? 2I NO ❑YES-#of Devices:
<br /> SELECT SCOPE(REQUIRED)_ ❑ Data ❑ Intercom El Thermostat ❑Audio El Secure Access ❑Security System
<br /> El 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): ft '.D !'f;!i V;t irS
<br /> ] CODE COMPLIANCE
<br /> IS THIS PERMIT EDUCATION,INSTITUTIONAL,HEALTH AND/OR PERSONAL CARE FACILITIES: ,'NO ❑YES--See Below&Pg.2
<br /> 111 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:,,CrNO EYES-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 /> CONTACT;INFORMATION-
<br /> OWNER NAME: ( .rAI)e i Pt:,-o j t )4-y,,r`g TENANT BUSINESS NAME(If Commercial):
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<br /> OWNER MAILING ADDRESS: STREET CM I~ Vi.Q;l.j i'i r its? ,C)-(-
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<br /> CrrY F k (.-— ' STATE Ntki-VA ZIP "l ,qQ E
<br /> OWNER PHONE: :rP,„5,2,;),--CiirAn1 OWNER EMAIL: `t�_,l'N(`•,rjk ),I,P.1:Qk -41,t17'dG: 11*ii-
<br /> CONTRACTOR NAME: ES PR( 01
<br /> CONTRACTOR ADDRESS: sTREEr 46 CI r✓
<br /> CRY 1cOre)re j‘-'-i- STATE VVPI ZIP Ci :Q01
<br /> CONTRACTOR PHONE:"` - 0)f-4 `-p) CONTRACTOR EMAIL:Sajr-CA(DG(,S h i— ,,1ci,,, C,..^t,pr
<br /> CONTRACTOR LIC.#(REQUIRED):(--;)-31-k E.A(-11-(,.c. .j g[ CITY OF EVERETT BUSINESS LIC#(REQUIRED): ��(P;c)Sg
<br /> PRIMARY CONTACT: El OWNER NpONTRACTOR ❑OTHER(Please Specify)
<br /> CONTACT NAME: p ' CONTACT PHONE:4as_ L�,0� .�
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<br /> I- �1 1 C"- CONTACT EMAIL: .'1'1riA(a1'isin p0 -t-i 1'30,, , c�i`";S.-V1
<br /> AGREEMENT:1 hereby certify that 1 have read and examined this application and know the same to be fr e a d correct. All provisio s 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 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 /> Owner7Authoriized Agent Signature Date (Revised 1/11/2019) Page 1-Application
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