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CTRICAL PERMIT APPLTATION
<br /> #411 -4.
<br /> Nogg4CITY OF EVERETT PERMIT SERVIC2
<br /> 3200 CEDAR STREET,EVERETT.WA 98201
<br /> (P)425-257-8810 I FAX 425-257-8857 I(E)everetteps@everettwa.gov 1 www.everettwagovipermits
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<br /> PROJECT ADDRESS: 1 11 1,1) it.S in t„ 1.:
<br /> ' 1 ( BUILDING AREA: sq ft
<br /> PROJECT TYPE: LI NEW CONSTRUCTION LI ADDITION "Il TENANT IMPROVMENT El REMODEL
<br /> BUILDING USE: CI SFR El TOWNHOUSE Xi DUPLEX D ADU MULTI-FAMILY-#OF UNITS: El COMMERCIAL
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<br /> CONTRACT PRICE OF WORK:$ (7RotI. ,..-- ASSOCIATED BUILDING PERMIT#(if applicable):
<br /> DESCRIBE SCOPE OF WORK: , /LA i'-t-e,i,- e 1- 4A( ( VI
<br /> 0,lottrr. fLi V-1 d--- (0 — s(0
<br /> )
<br /> THIS INSTALLATION INCLUDES THE FOLLOWING SCOPE: (SELECT ALL THAT APPLY)
<br /> UNE VOLTAGE WORK? CI NO C] '(ES-Select Scope: 71 Service CI Feeder 3 Circuits-#: 7" 171 Complete Re-wire
<br /> LOW VOLTAGE WORK? CI NO El YES-#of Devices:
<br /> SELECT SCOPE(REQUIRED): 0 Data LI Intercom ID Thermostat 0 Audio [A Secure Access El Security System
<br /> El 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 /> El Other(List All):
<br /> VW"4nirf1If* -74-SIV.4t0iiiiMPE.-11.7::.;g:II:1:,:.:::;7717:71:7RWVIVIrrEMMIlat.441423:n2ftV
<br /> IS THIS PERMIT EDUCATION,INSTITUTIONAL, HEALTH AND/OR PERSONAL CARE FACILITIES: Ill NO III YES--See Below&Pg.2
<br /> By checking this box, I am stating that I have read and understand all of WAC 296-4613-900,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 UCENSURE: ENO OYES-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.
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<br /> OWNER NAME: 1 ti- .e,Yr4._ a() ---c TENANT BUSINESS NAME(If c.ommercial):
<br /> OWNER MAILING ADDRESS: stREET —1 I ( Lit) (tt4 (V'"-- ) 12_4-A
<br /> CITY 4,,,,vo,ti. STATE 04 ZIP
<br /> OWNER PHONE: Oil L ii 2-li IP).- OWNER EMAIL:
<br /> CONTRACTOR NAME:
<br /> is
<br /> CONTRACTOR ADDRESS: 1-TREET q 0/ (,4) ' pt,A(kl S/--- six— 1, ›
<br /> CITY "ii--04.2a --11) crfip. q gVq$T,a,---- ZIP
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<br /> CONTRACTOR PHONE:7 3-441 1 I ri-17.tr, CONTRACTOR EMAIL: Wfri- a jeetseh 'Pzi) i s' r —C----'' "C, I
<br /> CONTRACTOR LIC.#(REQUIRED): CITY OF EVERETT BUSINESS UC.#(REQUIRED):331S ) 4 -1
<br /> PRIMARY CONTACT: DOWNER reit.ONTRACTOR gi eTHER(Please Specify) ifi/Lef.f 01
<br /> CONTACT NAME: CONTACT PHONE:
<br /> 'NV
<br /> 12O(e V (2 (6-- CONTACT EMAIL:
<br /> AGREEMENT.I hereby certify that I have read and examined this application and know the seine to be true and correct. All provisions of laws and ordinances governing this
<br /> type of work will be completed whether specified herein or not. The granting of a portrait 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 authoifzed by the owner of this property to perform the work for which application is made and I
<br /> comply with the State Contractors Law 18.27 RCW and 296.200 WAC, City of Everett Official Use Only
<br /> , „...,...,, PERMIT#:
<br /> I11 11 tel
<br /> --,..,
<br /> Owner/Authorized Agent Signature ''''' Date (Revised 1/11/2019) Page'I-Application
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