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a Agiew ELECTRICAL nkMIT & FIRE ALARM PLVIIT APPLICATION
<br /> CITY OF EVERETT PERMIT SERVICES
<br /> 3200 CEDAR STREET, EVERETT,WA 98201
<br /> (P)425-257-8810 I FAX 425-257-8857 I (E)everetteps@everettwa.gov I www.everettwa.gov/permits
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<br /> PROJECT ADDRESS: / (jam d'}2 (w4- %Se2Oef
<br /> PROJECT TYPE: 0 NEW CONSTRUCTION 0 ADDITION 0 TENANT IMPROVMENT Al REMODEL
<br /> BUILDING USE: ,r4 SFR 0 TOWNHOUSE 0 DUPLEX 0 ADU ❑MULTI-FAMILY-#OF UNITS: 0 COMMERCIAL
<br /> BUILDING AREA: 3./ 00 sq ft
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<br /> CONTRACT PRICE OF WORK:$ 4 00 ASSOCIATED BUILDING PERMIT#(if applicable): B/806 •--00
<br /> IS THIS LOW VOLTAGE WORK? ® NO 0 YES-#OF DEVICES:
<br /> IS THIS A FIRE ALARM PERMIT? ®NO 0 YES-Plans required for review(Both Electrical and Fire Department inspections are required)
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<br /> DESCRIPTION OF WORK: Acre etpe tzt s«/' ©u fie/Z5, 1✓�e Ol,c/s7�.e 4.:94974
<br /> Odd One ©u 1144 I 1n s foci( Creneaotrof2 infeRIock 14I If
<br /> THIS SECTION APPLIES TO ALL EDUCATION,INSITUTIONAL,HEALTH AND/OR PERSONAL CARE FACILITIES:
<br /> By checking thisbox, I am stating that I have read and understand all of WAC 296-46B-900,selected the specific reason on page2
<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 /> ATTENTION OWNERS:THIS SECTION IS FOR OWNERS PERFORMING WORK AS THE CONTRACTOR WITHOUT ELECTRICAL LICENSURE:
<br /> in Pursuant to RCW 19.28.261,property owners and leaseholders cannot perform electrical work on buildings for rent,sale,or lease without
<br /> the proper electrical licensing and certification,or exemption.By checking this box,I am stating that I have completed and signed the
<br /> See Page 3 AFFIDAVIT on page 3 of this application to receive an exemption from this licensing/certification requirement.
<br /> CONTACT INFO MATZO!1
<br /> OWNER NAME: Vila' , r(Ca �i/, !.I (,t 1C TENANT BUSINESS NAME(If Commercial):
<br /> OWNER MAILING ADDRESS: d STREET g3/6 / m B� f�
<br /> C�Q ��� CITY STATE Grri�I ZIP 9eyn a OQ
<br /> OWNER PHONE: :12c- SO t)WNER EMAIL: L VC if l e o7 D(.. 1x 11
<br /> CONTRACTOR NAME: 0 y4
<br /> CONTRACTOR ADDRESS: STREET
<br /> CITY STATE ZIP
<br /> CONTRACTOR PHONE: ICONTRACTOR EMAIL:
<br /> CONTRACTOR LIC.#(REQUIRED): CITY OF EVERETT BUSINESS LIC.#(REQUIRED)
<br /> PRIMARY CONTACT: gl OWNER 0 CONTRACTOR 0 OTHER(Please Specify)
<br /> CONTACT NAME: CONTACT PHONE:
<br /> CONTACT EMAIL:
<br /> AGREEMENT..I hereby certify that!have read and examined this application and know the same to be true and correct. All provisions of laws and ordinances
<br /> 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
<br /> 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
<br /> work for which application is made and I comply with the State Contractors Law 18.27 RCW and 296.200 WAC.
<br /> City of Everett Official Use Only
<br /> PERMIT#
<br /> // — of --1g
<br /> Owner/Authorized Agent Signature Date (Revised 10/30/2018) Page 1 ofa L
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