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ELECTRICAL AIRMIT & FIRE ALARM PERMIT APPLICATION
<br /> CITY OF EVERETT PERMIT SERVICES
<br /> grt 3200 CEDAR STREET, EVERETT,WA 98201
<br /> (P)425-257-8810 I FAX 425-257-8857 I(E)everetteps@everettwa.goy I www.everettwa.gov/permits
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<br /> PROJECT ADDRESS: i s'2. 09-)i,) 1 SW A
<br /> PROJECT TYPE: 0 NEW CONSTRUCTION LI�ADDITION 0 TENANT IMPROVMENT 0 REMODEL
<br /> BUILDING USE: 0 SFR 0 TOWNHOUSE 0 DUPLEX 0 ADU ❑MULTI-FAMILY-#OF UNITS: CCOMMERCIAL
<br /> BUILDING AREA: sq ft
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<br /> CONTRACT PRICE OF WORK:$ f 50 U ASSOCIATED BUILDING PERMIT#(if applicable):
<br /> IS THIS LOW VOLTAGE WORK? 0 NO .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:
<br /> Ce- v� �{i t C-11.‘ I.S - .0"
<br /> C o.
<br /> THIS SECTION APPLIES TO ALL EDUCATION,INSITUTIONAL,HEALTH AND/OR PERSONAL CARE FACILITIES:
<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 /> ATTENTION OWNERS:THIS SECTION IS FOR OWNERS PERFORMING WORK AS THE CONTRACTOR WITHOUT ELECTRICAL LICENSURE:
<br /> ❑ 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 /> EEISiTACT Ii`iF Tf
<br /> OWNER NAME: iJ ( .2M C f2._ TENANT BUSINESS NAME(IfCommercial): LI A \ P.i� tai
<br /> OWNER MAILING ADDRESS: STREET I C C6" (A—HV
<br /> CITY J-0 ( Orfti STATE (jj l"- ZIP r 2,0 s-
<br /> OWNER PHONE: Ce) C A 1. Csei f; t, OWNER EMAIL: D i - S c(
<br /> CONTRACTOR NAME: (A.A-c
<br /> CONTRACTOR ADDRESS: STREET `? 7 (iy O 0 57-1 S A �}
<br /> CITY C' ,/ (P STATE CA I ZIP
<br /> CONTRACTOR PHONE: CONTRACTOR EMAIL:
<br /> CONTRACTOR LIC.#(REQUIRED): CITY OF EVERETT BUSINESS LIC.#(REQUIRED):
<br /> PRIMARY CONTACT: 0 OWNER &CONTRACTOR 0 OTHER(Please Specify)
<br /> CONTACT NAME: CONTACT PHONE: 2, p (o QC/ 5 (L(
<br /> L ` $ CONTACT EMAIL: A, 6 f 6 k i^ 6-c.2
<br /> AGREEMENT:I hereby certify that I 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 /> Q As ( 2 ( ( 20
<br /> 0 /Authorized Agent gDate (Revised 10/30/2018) age 1 of 3
<br /> 9 Signature7
<br />
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