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<br /> ELECTRICAL PERMIT APPLICATION
<br /> EVERETT CITY OF EVERETT PERMIT SERVICES
<br /> 3200 CEDAR STREET,EVERETT,WA 98201
<br /> WASHINGTON (P)425-257-8810 1 FAX 425-257-8857 1(E)everetteps@everettwa.gov I www.everettwa.gov/permits
<br /> PROJECT SITE INFORMATION .
<br /> PROJECT ADDRESS: t 13 1:2.. �,,,,,\,ear T(;v R__ Fuca - fe Z.3 BUILDING AREA: sq ft
<br /> PROJECT TYPE: ❑ NEW CONSTRUCTION ❑ADDITION [ 1'.-TENANT IMPROVMENT ❑ REMODEL
<br /> BUILDING USE: ❑SFR El TOWNHOUSE ❑ DUPLEX ❑ADU ❑ MULTI-FAMILY-#OF UNITS: ❑ COMMERCIAL
<br /> ' ELECTRICAL APPLICATION.INFORMATION..& DESCRIPTION.OF WORK .
<br /> CONTRACT PRICE OF WORK:$ � ) 1St, ASSOCIATED BUILDING PERMIT#(if applicable):
<br /> DESCRIBE SCOPE OF WORK: 1 7' 1.4L-c.,tj-etc ";0 r,,,"/► L;r,.�...,�- . - 4/ (, v...(1.,--1—, O o
<br /> 2, C;. C..v un:�' -I.0 S Q.✓'✓`W .` 4-les- Ard..-r1.1�- 4.0 ,4 ( !-- L-Al-ii-, L.,:,...., tA: i i
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<br /> Attyt .
<br /> --11-tz..4.4 �.� N,'.v''
<br /> THIS INSTALLATION INCLUDESTHE FOLLOWING SCOPE: (SELECT ALL THAT APPLY)
<br /> LINE VOLTAGE WORK? ❑ NO FIC'ES-Select Scope: CIService UfFeeder ❑Circuits-#: ❑ Complete Re-wire
<br /> N
<br /> LOW VOLTAGE WORK? ❑ NO YES-#of Devices: I
<br /> SELECT SCOPE(REQUIRED): ❑ Data ❑ Intercom ['Thermostat ❑Audio ❑Secure Access ❑Security System
<br /> ❑ 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 /> : CODCCOMPLIANCE
<br /> IS THIS PERMIT EDUCATION,INSTITUTIONAL,HEALTH AND/OR PERSONAL CARE FACILITIES: 10"—NiO ❑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: PO 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.:I NFORMATIONM
<br /> OWNER NAME: TENANT BUSINESS NAME(If Commercial):
<br /> OWNER MAILING ADDRESS: STREET
<br /> CITY STATE ZIP
<br /> OWNER PHONE: OWNER EMAIL:
<br /> CONTRACTOR NAME: APIC 1t=I EL 'f,(, 1 ,!`'
<br /> CONTRACTOR ADDRESS: STREET 9 0 Li S le......4-e../- A / ✓I g-
<br /> CITY CITY K, v-t.;-1., STATE w� ZIP `` 6(..).3
<br /> CONTRACTOR PHONE: (1Z l;y I-s33Ly 3 CONTRACTOR EMAIL: GLa/t.w cviAS 4 to„�-v;',4,1 L ci-tet),Ay • C(f)/11.
<br /> CONTRACTOR LIC.#(REQUIRED) CITY OF EVERETT BUSINESS LIC.#(REQUIRED): 1' o Z
<br /> PRIMARY CONTACT: DOWNER R ONTRACTOR ❑OTHER(Please Specify)
<br /> CONTAC//,NAME: CONTACT PHONE: —1 Z c_ k2(V 1 -3 ( . I t6
<br /> AOIce,y-N c i.t',f L CONTACT EMAIL: teAnnut....,6..)a.,4,0,- E ir,L.kY.:LcaGi;› ,C.[Jiyt
<br /> AGREEMENT:t hereby certify that I have read and examined this application and know the same to be trk and correct. All provisions of laws and orbinancei 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 ownerof thi roperty to perform the work for which application is made and I
<br /> comply with the State Contrac.rs Law 18.27 RCW and 296.200 WAC. City of Everett Official Use Only
<br /> PERMIT#:
<br /> E \oi bu- Itoro
<br /> Owner/Authori'Agent Signature Date (Revised 1/11/2019) Page 1-Application
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