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NININ <br /> 111161 ELECTRICAL PERMIT APPLICATION <br /> CITY OF EVERETT PERMIT SERVICES <br /> EVERETT 3200 CEDAR STREET;EVERETT,WA 98201 <br /> WASHINGTON (P)425-257-8810 I FAX 425-257-8857 1(E)everetteps@everettwa.gov www.everettwa.gov/permits <br /> PROJECT RITE INFORMATION <br /> PROJECT ADDRESS: f 4.3 Q Ca.S f Yl-t1 h- d (J BUILDING AREA: sq ft <br /> PROJECT TYPE: ❑ NEW CONSTRUCTION ❑ADDITION ❑TENANT IMPROVMENT ❑REMODEL <br /> BUILDING USE: I SFR --TOWNHOUSE El DUPLEX El ADU ❑ MULTI-FAMILY-#OF UNITS: ❑COMMERCIAL <br /> ELECTRICAL APPLICATION INFORMATION & DESCRIPTION OF WORK - <br /> CONTRACT PRiCE OF WORK:$ j - 4 a t,,< 0}} ASSOCIATED BUILDING PERMIT#(if applicable): <br /> DESCRIBE SCOPE OF WORK: &AAA 1r-et. rt ti` CA--- ,..t. CV_ <br /> MVACS _o � <br /> THIS INSTALLATION INCLUDES THE FOLLOWING SCOPE: (SELECT ALL THAT APPLY) <br /> �-., �✓ <br /> LINE VOLTAGE WORK? El NO ❑YES-Select Scope:El Service ❑Feeder [I Circuits-#: El Complete Re-wire <br /> LE <br /> LOW VOLTAGE WORK? ❑ NO "YES-#of Devices: <br /> SELECT SCOPE(REQUIRED): ® Data ClIntercom hermostat El Audio ❑Secure Access El 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 Alt): <br /> CODE COMPLIANCE <br /> IS THIS PERMIT EDUCATION,INSTITUTIONAL,HEALTH AND/OR PERSONAL CARE FACILITIES: L:'�NO • YES--See Below&Pg.2 <br /> By checking this box, I am stating that I have read and understand all of WAC 296-468-900,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. OYES <br /> ARE YOU AN OWNER PERFORMING WORK AS THE CONTRACTOR WITHOUT ELECTRICAL LICENSURE: ENO OYES-See Below&Pg.3 <br /> f <br /> l 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 /> OWNER NAME: {. .' V 1 0 0 41.16 TENANT BUSINESS NAME(If Commercial): <br /> OWNER MAILING ADDRESS: STREET q ? C ' `.j't z; _ d D- <br /> om( `^'��.._L. `.'' STATE Oa ZIP <br /> OWNER PHONE/404r;-® "-F . 4461-1-c( OWNER EMAIL: <br /> CONTRACTOR NAME: f l(j // (j�9`�d., �' `t �(y_`"� //] <br /> CONTRACTOR ADDRESS: STREET `i 8 t —1T ' �.*1.. 8' J ,. <br /> CITY n/-) w„+'A✓ 4")V + 9. le_f . STATE v e`.. 21P d '.?Y7r J 61) <br /> � SGe �cY ' \CONTRACTOR PHONE--V) IC TRACTOR EMAIL: i7+ 6 ' :// V LLh � � <br /> CONTRACTOR LIC.#(REQUIRED): f1(.)YCt` -L'.., CITY OF EVERETT BUSINESS LIC.#(REQUIRED):£,}4 --'1 =i'-1 <br /> PRIMARY CONTACT: DOWNER QC6NTRACTOR OTHER(Please Specify) <br /> CONTACT NAME: CONTACT PHONE: - (;,i so;? ci' c C <br /> ( t_I`-•_ CONTACT EMAIL: <br /> AGREEMENT:I hereby certify that t have read and examined this application and know the same to be 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 t <br /> comply with the State Contractors Law 16.27 RCW and 296.200 WAC. City of Everett Official Use Only <br /> PERMIT#: <br /> (1 <br /> r L _IL] - E \Ro5- Da <br /> Owner/Authorized Aent Signature Date (Revised 1/11/2019) Page 1-Application <br />