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/ ELECTRICAL PERMIT APPLICATION
<br /> _
<br /> /y 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.govlpermits
<br /> ; , s, �}�,,� ,t�, Y �. .,,; .PROJECT SITE•INFO,RMATION .,. ... .. ,. � . ` ;..,°:>"_ .� � `�. .���. `<. ,. .
<br /> PROJECT ADDRESS: f CO
<br /> ��` I ► L BUILDING AREA: sq ft
<br /> PROJECT TYPE: Lj NEW CONSTRUCTION ❑ADDITION ( TENANT IMPROVMENT El REMODEL
<br /> BUILDING USE: SFR ❑TOWNHOUSE ❑DUPLEX ❑ADU ❑MULTI-FAMILY-#OF UNITS: ❑COMMERCIAL
<br /> s,r>;'... „ }tR O.ELECTRICAL APPLICATIONkINFORMATION;&1.0,ESCRIPTI;ON OFM RK , , ;;,k.,. „,
<br /> CONTRACT PRICE OF WORK:$ too . 00 ASSOCIATED BUILDING PERMIT#(if applicable):
<br /> DESCRIBE SCOPE OF WORK:
<br /> THIS INSTALLATION INCLUDES THE FOLLOWING,_,/ SCOPE: (SELECT ALL THAT APPLY)
<br /> .)NEVOLTAGE WORK? D.NO ICJ YES-SelectScgpe; ❑Service El Feeder ❑Circuits-#: ❑Complete Re-wire
<br /> LOW VOLTAGE WORK? ❑NO YES;;#of Devices: ,
<br /> SELECT SCOPE(REQUIRED): ❑ Data ❑ Intercom: [thermostat ❑Audio ❑ Secure Access. D.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 /> . ,:i , ';ng`°x..��``.�;�'l , t ;` t.nt\ xl.';t giLcODEfC,O.IVIPLIANCE, r,,A.,,, '.Rt�'.,�, .':.il<. tt`,3 ; i.�t.: P.,�,,..'itslr�l..Z..�`.'
<br /> IS THIS PERMIT EDUCATION,INSTITUTIONAL,HEALTH AND/OR PERSONAL CARE FACILITIES: nNO ETYES—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 DYES-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 /> k..:). ,.. )., ,"`.', .'... 'i;. ` `gn :,, .x P.PNTIRP7r INFORMATION CO' '` }. 't r::. s . <1'...:'
<br /> OWNER NAME: a.)n/ti V./AAa TENANT BUSINESS NAME(If Commercial):
<br /> OWNER MAILING ADDRESS: V sTRe r �2 ((n�rp \(�u'
<br /> �t JAAJdC�
<br /> c1TY & y STATE l (ZIP "( 7.��C
<br /> OWNER PHONE: 7 L - 1 !gl2.73 OWNER EMAIL:.
<br /> CONTRACTOR NAME: gs heating
<br /> CONTRACTOR ADDRESS: sTREET3409 everett ave
<br /> cirr everetf STATE w ZIP 98201
<br /> CONTRACTOR PHONE:425-252-4402 CONTRACTOR EMAIL:dawn@gsheating.com
<br /> CONTRACTOR LIC.#(REQUIRED):GSHEAHC8218R CITY OF EVERETT BUSINESS LIC.#(REQU[RED):60058
<br /> PRIMARY CONTACT: ❑OWNER ✓❑CONTRACTOR ❑OTHER(Please Specify)
<br /> CONTACT NAME: CONTACT PHONE:425-252-4402
<br /> dawn weimer CONTACT EMAIL:dawn@gsheating.com
<br /> AGREEMENT I hereby certify that 1 have read and examined this application and know the same to be true and correct. Ali 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 1 am authorized by the owner of this property to perform the work for which application is made and
<br /> comply with the State Contractors Law 18.27 RCW and 296.200 WAC. City of Everett Official Use Only
<br /> PERMIT#:
<br /> dawn weimer — )281 t E °10,(1, ...-004
<br /> Owner/Authorized Agent Signature Dat (Revised 1/11/2019) Page 1-Application
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