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ELECTRICAL PERMIT APPLICATION CITY OF EVERETT PERMIT SERVICES EVERETT 3200 CEDAR STREET,EVERETT,WA 98201 WASHINGTON (P)425-257-8810 1(E)PermitServices@everettwa.gov I wvm.everettwa.gov/permits qT,Z TEINFORMATION, ' PROJECT ADDRESS: IBUILDING AREA: sq ft PROJECT TYPE: ❑ NEW CONSTRUCTION ❑ADDITION ❑TENANT IMPROVMENT 11 REMODEL BUILDING USE: ❑ SFR 11 TOWNHOUSE 0 DUPLEX 11 ADU 0 MULTI-FAMILY-#OF UNITS: 13 COMMERCIAL P-'AP 'INP VOCRIPTIOROFNPRK-1 0-TRICA AiDA TIPN," PRM T CONTRACT PRICE OF WORK:$ I' _, c_,(/, — r, JASSOCIATED BUILDING PERMIT#(if applicable): DESCRIBE SCOPE OF WORK: c v, 4, y ,, C, Ct THIS INSTALLATION INCLUDES THE FOLLOWING SCOPE: (SELECT ALL THAT APPLY) LINE VOLTAGE WORK? ❑ NO _>E]DES-Select Scope: 11 Service 11 Feeder 1:1 Circuits-#: ❑ Complete Re-wire LOW VOLTAGE WORK? ❑ NO 11 YES-#of Devices: SELECT SCOPE(REQUIRED): [3Data 0 Intercom El Thermostat 11 Audio 0 Secure Access ❑ Security System 11 Fire Alarm-Installations under this permit only include electrical wiring rough-in of the system.An additional Fire Alarm Permit is required for review of device location and installation approval. ❑ Other(List All): C AM. _Qmn IS THIS PERMIT EDUCATION, INSTITUTIONAL,HEALTH AND/OR PERSONAL CARE FACILITIES: f O IJ YES See Below&Pg.2 ❑ By checking this box, I am stating that I have read and understand all of WAC 296-46B-90 elected the specific reason on page 2 of this application(see next page),AND Plan Review is NOT required because I meet all of the following sub sections that do not See Page 2 require Plan Review. 11 ARE YOU AN OWNER PERFORMING WORK AS THE CONTRACTOR WITHOUT ELECTRICAL LICENSUREfM'O DYES-See Below&Pg. 3 ❑ Pursuant to RCW 19.28.261,property owners and leaseholders cannot perform electrical work on buildings for rent, sale,or lease without the proper electrical licensing and certification, or exemption. By checking this box, I am stating that I have completed and See Page 3 signed the AFFIDAVIT on page 3 of this application to receive an exemption from this licensing/certification requirement, T., CONTACT N IR MATT OWNER NAME: TENANT BUSINESS NAME(If Commercial): OWNER MAILING ADDRESS: STREET CITY STATE �kj 4) ZIP OWNER PHONE: 1 a5 3 S- s OWNER EMAIL: CONTRACTOR NAME: CONTRACTOR ADDRESS: STREET C11- CITY STATE ZIP CONTRACTOR PHONE: 1CONTRACTOR EMAIL: CONTRACTOR LIC.#(REQUIRED): CITY OF EVERETT BUSINESS LIC.#(REQUIRED. PRIMARY CONTACT: 11 OWNER 11 CONTRACTOR 11 OTHER(Please Specify) \V/ CONTACT NAME; CONTACT PHONE: CONTACT EMAIL: Jut. T AGREEMENT.•/hereby certify that/have read and examined this application and know the same to be true and correct All provisions of laws and'ordinances 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 vio1&joTGyn@F9 Fo VEiRcEaTyTother state or local law regulating construction or the performance of construction. That am authorized by the owner of this property to perfon-n th made and l comply with the State Contractors Law 18.27 RCW and 296.200 WAC. TCyA%T1A9M.1lWi Only PERMIT M I E Owner/Authorized Agent Sign'hture (,3 Date (Revised 41512022) Page 1-Application