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_ L EC ��RICAL PERMIT APPU ,,, irION <br /> CITY OF EVERETT PERMIT SERVICES <br /> sitiO <br /> d�' 3200 CEDAR STREET,EVERETT,WA 98201 <br /> (P)425-257-8810 1 FAX 425-257-8857 1(E)everetteps@everettwa.gov 1 www.everettwa.gov/permits <br /> PROJECT SITE INFORMATION <br /> PROJECT ADDRESS: 1 I 5 E ty e,feA..- Atiql( W/.\' BUILDING AREA: sq ft <br /> PROJECT TYPE: 0 NEW CONSTRUCTION 0 ADDITION TENANT IMPROVMENT 0 REMODEL <br /> BUILDING USE: 0 SFR 0 TOWNHOUSE 0 DUPLEX 0 ADU 0 MULTI-FAMILY-#OF UNITS: ❑ COMMERCIAL <br /> ELECTRICAL APPLICATION INFORMATION & DESCRIPTION OF WORK <br /> CONTRACT PRICE OF WORK: $ afyCo ,00 ASSOCIATED BUILDING PERMIT#(if applicable): <br /> DESCRIBE SCOPE OF WORK: <br /> SOV t (-)n rtolo, 0 h sql GS 4 bar l v l',c7/,r,�r-I- -t i v .�f��d vu� <br /> THIS INSTALLATION INCLUDES THE FOLLOWING SCOPE: (SELECT ALL THAT APPLY) <br /> LINE VOLTAGE WORK? ❑ NO 0 YES-Select Scope: 0 Service 0 Feeder 0 Circuits-#: 0 Complete Re-wire <br /> LOW VOLTAGE WORK? Eil NO 0 YES-#of Devices: <br /> SELECT SCOPE (REQUIRED). ❑ Data 0 Intercom 0 Thermostat 0 Audio 0 Secure Access 0 Security System <br /> 0 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: C NO 0 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: LINO OYES-See Below& Pg. 3 <br /> ❑ Pursuant to ROW 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: Be5A- (Jt <br /> , TENANT BUSINESS NAME(If Commercial): 32,ST iki/ <br /> OWNER MAILING ADDRESS: STREET <br /> CITY STATE ZIP <br /> OWNER PHONE: OWNER EMAIL: <br /> CONTRACTOR NAME: .-- t\1 R P)O ecS F1 - - t con-k\c,c kfle t:. . <br /> CONTRACTOR ADDRESS: STREET 9O'5O Alar COY), Dr 1v{ \e- aoc <br /> CITY ) i ?\,,,,r �\*(\ STATE �/�j- ZIP ](( �J <br /> CONTRACTOR PHONE: �0 77R �.YY3-f7 CONTRACTOR EMAIL: L At L e n S� 0 LVVL OAC, elec kv-:c`.'�caw) <br /> CONTRACTOR LIC.#(REQUIRED): E(. L jn ' IR f?5Gg i CITY OF EVERETT BUSINESS LIC.#(REQUIRED):05131 <br /> PRIMARY CONTACT: ❑OWNER 0 CONTRACTOR 0 OTHER(Please Specify) ' <br /> CONTACT NAME: CONTACT PHONE: 770 - ` 7a l " -311 99 <br /> S :Phanie C—cQr-� CONTACT EMAIL: t_isc e, \S r_ ®/ RQ,,,t 4, e-legAr;( • COW) <br /> AGREEMENT I hereby certify tha ave read and examined this application and know the same to be true and correct. Altpfovisions 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 /> aa,,, 3N / , D ,,- �. <br /> Owner/Authorized Agent ignature Date (Revised 1/11/2019) Page 1-Application <br />