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<br /> ELECTRICAL PERMIT APPLICATION
<br /> R CITY OF EVERETT PERMIT SERVICES
<br /> EVE R E Y� `I 3200 CEDAR STREET, EVERETT,WA 98201
<br /> WASHINGTON (P)425-257-8810 I FAX425-257-8857 1(E)everetteps@everettwa.gov 1 Www.everettwa.gov/permits
<br /> PROJECT SITE INFORMATION
<br /> PROJECT ADDRESS: . / 0S Deco L..ecI Df', BUILDING AREA: sq ft
<br /> PROJECT TYPE: ❑ NEW CONSTRUCTION ❑ADDITION El TENANT IMPROVMENT ®aREMODEL
<br /> BUILDING USE: tgl,SFR ❑TOWNHOUSE ❑ DUPLEX ❑ADU ❑ MULTI-FAMILY-#OF UNITS: ❑ COMMERCIAL
<br /> ELECTRICAL APPLICATION INFORMATION & DESCRIPTION OF WORK
<br /> CONTRACT PRICE OF WORK: $ 5 OD.°i ASSOCIATED BUILDING PERMIT#(if applicable):
<br /> DESCRIBE SCOPE OF WORK: I v i c c I C? v. ,L Q CCI,„ c,„._,„,c ,c,
<br /> THIS INSTALLATION INCLUDES THE FOLLOWING SCOPE: (SELECT ALL THAT APPLY)
<br /> LINE VOLTAGE WORK? ❑ NO ❑YES-Select Scope:,Service El Feeder El Circuits-#: ❑ Complete Re-wire
<br /> LOW VOLTAGE WORK? El NO ❑YES-#of Devices:
<br /> SELECT SCOPE(REQUIRED): ❑ Data ❑ Intercom El Thermostat ❑Audio ❑ Secure Access El 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 /> CODE COMPLIANCE
<br /> IS THIS PERMIT EDUCATION, INSTITUTIONAL,HEALTH AND/OR PERSONAL CARE FACILITIES: `Z NO ❑ YES--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: ENO IMYES-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 /> CONTACT INFORMATION
<br /> OWNER NAME: ___SG, vs.."£. 5 L,,A e�,_ TENANT BUSINESS!� NAME(If Commercial):
<br /> OWNER MAILING ADDRESS: STREET , ( C 5 1)WC,1,,,ircc.) LJ R R.
<br /> CITY Ck,E,C.f1 STATE LA ii..)- ZIP 5;c1(✓' f�
<br /> OWNER PHONE: '12.,c---”? 37 ` l J OWNER EMAIL: L ii,,''T 1-,- 'S L k. }) ,),✓,,,Ileo k, '.,,.Co"',
<br /> CONTRACTOR NAME:
<br /> CONTRACTOR ADDRESS: STREET
<br /> CITY S1 ATE ZIP
<br /> CONTRACTOR PHONE: CONTRACTOR EMAIL:
<br /> CONTRACTOR LIC.#(REQUIRED): CITY OF EVERETT BUSINESS LIC.#(REQUIRED):
<br /> PRIMARY CONTACT: 12•WNER ❑CONTRACTOR ❑OTHER(Please Specify)
<br /> CONTACT NAME: CONTACT PHONE: L' L c 7 3 7 .diEe , '
<br /> l CONTACT EMAIL: c L 0/--,
<br /> 04.)-!nAGREEMENT.:I hereby certify that I have read and examined this application and know the same to be true and corrprovisions 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 I am authorized 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 /> 0"),
<br /> Owned uthorized Ag ig tura Date (Revised 1/11/2019) Page 1-Application
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