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OirErrELECTRICAL PERMIT APPLICATION <br /> CITY OF EVERETT PERMIT SERVICES <br /> 3200 CEDAR STREET, EVERETT,WA 98201 <br /> (P)425-257-8810 I FAX 425-257-8857 1(E)everetteps@everettwa.gov 1 www.everettwa.gov/permits <br /> PROJECT SITE INFORMATION <br /> PROJECT ADDRESS: /1,9,4!) CZ°l n0 ge/ g 3/6 <br /> BUILDING AREA: sq ft <br /> PROJECT TYPE: 0 NEW CONSTRUCTION 0 ADDITION 0 TENANT IMPROVMENT „El REMODEL <br /> BUILDING USE: 0 SFR 0 TOWNHOUSE 0 DUPLEX 0 ADU E MULTI-FAMILY-#OF UNITS: 0 COMMERCIAL <br /> ELECTRICAL APPLICATION INFORMATION & DESCRIPTION OF:WORK <br /> CONTRACT PRICE OF WORK:$ /5�` ASSOCIATED BUILDING PERMIT#(if applicable): <br /> DESCRIBE SCOPE OF WORK: �� � 2�� Lx) <br /> A <br /> THIS INSTALLATION INCLUDES THE FOLLOWING SCOPE: (SELECT ALL THAT APPLY) <br /> LINE VOLTAGE WORK? 0 NO BYES-Select Scope: 0 Service 0 Feeder 0 Circuits-#: 487 0 Complete Re-wire <br /> LOW VOLTAGE WORK? IN NO 0 YES-#of Devices: <br /> SELECT SCOPE(REQUIRED): ❑ 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 /> ❑Other(List All): <br /> CODE CtMPLIANCE <br /> IS THIS PERMIT EDUCATION,INSTITUTIONAL, HEALTH AND/OR PERSONAL CARE FACILITIES: la NO 0 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 OYES-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: 1`?X,r I` d-e7 TENANT BUSINESS NAME(If Commercial): <br /> OWNER MAILING ADDRESS: STREET k'").._U <br /> CITY vteAz f STATE Lt./SQ, ZIP <br /> OWNER PHONE: OWNER EMAIL: <br /> CONTRACTOR NAME: �7 �' � <br /> i :Y. ji► <br /> CONTRACTOR ADDRESS: STREET al ,A k -) wtvr-tA 2L_ <br /> CITY \Q( -s"—Qy-c) %5 /�.STATE W fid / ZIP <br /> CONTRACTOR PHONE: ��_3 7.-//� CONTRACTOR EMAIL: 5LL11 e1 C Y', @ L i' Yin,�`/.Cyit <br /> CONTRACTOR LIC.#(REQUIRED) y„J • cZ 95i CITY OF EVERETT BUSINESS LIC.#(REQUIRED): 73•---/ <br /> PRIMARY CONTACT: ❑OWNER Si'CONTRACTOR ❑OTHER(Please Specify) <br /> CONTACT NAME: CONTACT PHONE: ccsf S$ ?�7/. <br /> CONTACT EMAIL: AE,,.�4, ( 4 i Q Lyya,/) (i <br /> AG EMENT:I herebycciifyytthat I have read and examined this application and know the same4be true 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 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 /> VVZs- EI0 -b�Own r/ ¢ed Agent ature (Revised 1/11/2019) <br /> ( a9e1APPIation <br />