1517 BROADWAY 2019-07-12 - Laserfiche WebLink

i - 4 Olen. ELECTRICAL PERMIT APPLICATION 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 1 www.everettwa.gov/permits PROJECT SITE INFORMATION CIO PROJECT ADDRESS: /57 7 rUat .( BUILDING AREA: f yv(1 sq fft PROJECT TYPE: 0 NEW CONSTRUCTION 0 ADDI+ION 0 TENANT IMPROVMENT raREMODEL BUILDING USE: L7 SFR 0 TOWNHOUSE 0 DUPLEX 0 ADU 0 MULTI-FAMILY-#OF UNITS: 0 COMMERCIAL ELECTRICAL APPLICATION INFORMATION &DESCRIPTION OF WORK CONTRACT PRICE OF WORK:$ ASSOCIATED1BUILDING PERMIT#(if applicable): DESCRIBE SCOPE OF WORK: R[�Wk G C>C e/ 1.,Q,I k S. F: /2- THIS INSTALLATION INCLUDES THE FOLL WING SCOPE: (SELECT ALL THAT APPLY) LINE VOLTAGE WORK? VISE y " YES-Select Scope: Q Service 0 Feeder circuits-#: .� M Complete Re-wire LOW VOLTAGE WORK? Lt7 NO ❑YES-#of Devices: SELECT SCOPE(REQUIRED): 0 D 0 Intercom 0 Thermostat 0 Audio 0 Secure Access 0 Security System ire Alarm-Installations under this permit only include electrical wiring rough-in of the system.An additional ire Alarm Permit is required for review of device location and installation approval. 0 Other(List All): CODE COMPLIANCE IS THIS PERMIT EDUCATION,INSTITUTIONAL,HEALTH AND/OR PERSONAL CARE FACILITIES: 0 NO 0 YES--See Below&Pg.2 ❑ 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 YOU12) WNER PERFORMING WORK AS THE CONTRACTOR WITHOUT ELECTRICAL LICENSURE: ❑NO ES Y -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 without the proper electrical licensing and certification,or exemption. By checking this box, I am stating that I have completed and See Page 3 signed the AFFIDAVIT on page 3 of this application to receive an exemption from this licensing/certification requirement. .:CONTACT:XRFORMA"1'ION OWNER NAME: '\(4.t Hevk(ir',,,,,I TENANT BUSINESS NAME(If Commercial): OWNER MAILING ADDRESS: STREET Z.If/S- 4/0".' C/ p CITYfL.I,f 7 J STATE /� ZIP OWNER PHONE: OWNER EMAILy,.. CONTRACTOR NAME 5.G'L'I<° CONTRACTOR ADDRESS: STREET CITY STATE ZIP CONTRACTOR PHONE: CONTRACTOR EMAIL: CONTRACTOR LIC.#(REQUIRED): CITY OF EVERETT BUSINESS LIC.#(REQUIRED): PRIMARY CONTACT: O'OWNER ❑CO NTRACTOR El OTHER(Please Specify) CONTACT NAME• j CONTACT PHONE: K , �.� ��c� CONTACT EMAIL: Ku)ii' paitw. (o t— AGREEMENT:I hereby certify that I have read and examined this application and know the same to be true and correct. Allrovisions L 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 wCity f Everettk for wchOfficial application is Us ma Only and I comply with the State Contractors Law 18.27 RCW and 296.200 WAC. PERMIT#: E0 \9 o3, oo Owner/Authoriz•; Agent Signature Date (Revised 1/11/2019) Page 1-Application