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ELECT- PER: 0T APPLICATION <br /> ° CITY OF EVERETT PERMIT SERVICES <br /> ¢T32 <br /> CITY <br /> ' 00 CEDAR STREET, EVERETT,WA 98201 <br /> ��� (P)425-257-8810 I FAX 425-257-8857 I(E)everetteps@everettwa.gov I www.everettwa.gov/Permits v� <br /> ``.\ <br /> PROJECT'\ ITE INFORMATION <br /> PROJECT ADDRESS: V--o4 �� Z14��c,� \�\\ �t c� BUILDING AREA: sq ft <br /> a I <br /> PROJECT TYPE: 0 NEW CONSTRUCTION 0 ADDITION 0 TENANT IMPROVMENT 0 REMODEL <br /> BUILDING USE: 0 SFR 0 TOWNHOUSE 0 DUPLEX 0 ADU 0 MULTI-FAMILY-#OF UNITS: 0 COMMERCIAL <br /> ' ELECTRICAL APPLICATION INFORMATION:4'DEScRIPTIOPO 1: w WORT <br /> CONTRACT PRICE OF WORK:$1 Do-- (ASSOCIATED BUILDING PERMIT#(if applicable): <br /> DESCRIBE SCOPE OF WORK: Lc."--,,;.1 -N\ - \oc\:',( r\\ c,c t..,, �C-`,.IN,,,,A ) \ C <br /> 1 <br /> THIS INSTALLATION INCLUDES THE FOLLOWING SCOPE: (SELECT ALL THAT APPLY) <br /> LINE VOLTAGE WORK? 0 NO 0 YES-Select Scope: 0 Service 0 Feeder 0 Circuits-#: 0 Complete Re-wire <br /> LOW VOLTAGE WORK? 0 NO 0 YES-#of Devices: <br /> SELECT SCOPE(REQUIRED): <br /> 0 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 /> CI Other(List All): <br /> CODE..COMPLIIANCE' <br /> IS THIS PERMIT EDUCATION,INSTITUTIONAL,HEALTH AND/OR PERSONAL CARE FACILITIES: 0 NO CI 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: ONO DYES-See Below&Pg. 3 <br /> au Pursuant to RCW 19.28.261, property owners and leaseholders cannot perform electrical work on buildings for rent,sale, or lease <br /> liv-4 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 licensin rtification requirement. <br /> CONTACT•I NFORMATIOrf <br /> `- %`�\\ 1.....L Q.., TENANT BUSINESS NAME(If Comm cial . c, \ �. SRN,* <br /> i OWNER NAME: C,ve,,,�; <br /> OWNER MAILING ADDRESS: STREET j n „j(-N.i,\ L.c\t.rs,cv, ‘•NM, `-i0- 4100 <br /> C <br /> ��' � ZIP \4.k ` t� <br /> CITY _i-t V STATE � <br /> OWNER PHONE: .sWI R EMAIL:° moo. �.4� �. <br /> CONTRACTOR NAME. a ....alp' ��42.- <br /> CONTRACTOR ADDRESS: 'STREET �� -1Nw \ AC) <br /> CITY \L-LI, c,,VN-..C..- .. STATE C. si ZIP��� \�� <br /> CONTRACTOR PHONE: ,_,_ RACTOR EMAIL: lamI <br /> CONTRACTOR LIC.#(REQUI- D): l • , CITY OF EVERETT BUSINESS LIC.#(REQUI D): <br /> PRIMARY CONTACT: 0 OWNER 0 CONTRACTOR ■ OTHER(Please Specify) <br /> CONTACT NAME: CONTACT PHONE: 509 LSCI '1g21 <br /> .4)t f ( -- CONTACT EMAIL: , <br /> AGREEMENT:I 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 <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 <br /> r for <br /> Ewhictt Officiation <br /> atil n Use mais y e and I <br /> comply with the State Contractors Law 18.27 RCW and 296.200 WAC. <br /> PERMIT#: <br /> E kck0 -- Com <br /> �'"•��� \� 2 19 Pa a 1-Application <br /> Owner/Authorized Agent Signature Date (Revised 1/11/ 0 ) 9 <br />