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ELECT IBCCAL PERWIT APPUCATOON
<br /> .,•: -:)r CITY OF EVERETT PERMIT SERVICES
<br /> , 3200 CEDAR STREET,EVERETT,WA 98201
<br /> ; ;
<br /> (P)425-257-8810 i FAX 425-257-8857 I(E)everetteps@everettwa.gov I www.everettwa.gov/permits —
<br /> PROJECT ADDRESS: `IC- 5c„) Eve.4'42.4"1--i' t.c JI b2c_r. BUILDING AREA: 215-, c900 sq ft
<br /> PROJECT TYPE: ® NEW CONSTRUCTION 0 ADDITION a-TENANT IMPROVMENT CI REMODEL
<br /> BUILDING USE: 0 SFR ©TOWNHOUSE 0 DUPLEX 0 ADU D MULTI-FAMILY-#OF UNITS: .COMMERCIAL
<br /> i ELECTRECAL APPMCATtOR EE FOR ATEGN &:, E CR PTCCEI OF WO
<br /> RK
<br /> CONTRACT PRICE OF WORK: $ 1Z (,/;2 , o m ASSOCIATED BUILDING PERMIT#(if applicable):
<br /> DESCRIBE SCOPE OF WORK: ter. - ; - it 3 i) YUew (-.AT-6 . 4.- . , ;,- - r.:,: . ' +a ' 1
<br /> i''n>�'cke.,_ i- Mi...(A--,1 1 6) /Ue Coax -dor- Ti),
<br /> THIS INSTALLATION INCLUDES THE FOLLOWING SCOPE: (SELECT ALL THAT APPLY)
<br /> LINE VOLTAGE WORK? UNO D YES-Select Scope: Cl Service 0 Feeder 0 Circuits-#: 0 Complete Re-wire
<br /> LOW VOLTAGE WORK? D NO Ig---YES-#of Devices: 3 V
<br /> SELECT SCOPE(REQUIRED): Mate 0 Intercom 0 Thermostat ❑Audio
<br /> 0 Secure Access I 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 /> a-Other(List All): CA-TV
<br /> _ CODE COMPLEANCE
<br /> IS THIS PERMIT EDUCATION,INSTITUTIONAL, HEALTH AND/OR PERSONAL CARE FACILITIES:
<br /> 0 a YES--See Below&Pg.2
<br /> 0 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 /> 1 See Page 2 require Plan Review.
<br /> TARE YOUAN OWNER PERFORMING WORK AS THE CONTRACTOR WITHOUT ELECTRICAL LICENSURE:ONO OYES-See Below&Pg.3
<br /> 0 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.CONTQCT INFORMATION
<br /> OWNER NAME:PN,c_/c L3....,.,A. TENANT BUSINESS NAME(If Commercial): )ur zk. * r`1►,,c:k.._
<br /> OWNER MAILING ADDRESS: STREET 3-f Q /S 11...,,, F-Ve-r''e- /�4- ALM
<br /> CITY Fu,..,-, '/T- - STATE /...),,,. ZIP 9 Q ZOy/
<br /> 1OWNER EMAIL: /1 i..4.)4-1.1/ cii.�
<br /> / dd ,T
<br /> hJctc.A c- ,�r.
<br /> !OWNER PHONE: ... .... -_.._ ,
<br /> (CONTRACTOR NAME: Co.,. 4 gr A/� —• �L- --
<br /> CONTRACTOR ADDRESS: STREET 3o14' �/i7Ay !7/ `ie
<br /> CITY / .Pg fr - STATE t) ZIP c? Z6/
<br /> (CONTRACTOR PHONE1 'ZS)3/7-$Z5 (CONTRACTOR EMAIL: OF EVERETT US_ e9 LIC.#/REQUIRED co,.-1
<br /> CONTRACTOR LIC.#(REQUIRED): 5EAC_CCI'? PIDO -.,.. BUSINESS LIC #(R Q.. ...
<br /> PRIMARY CONTACT: 0 OWNER CONTRACTOR 0 OTHER(Please Specify)
<br /> CONTACT NAME: CONTACT PHONE: (i/ZS) Zoo- 76 Z /
<br /> Ck.,,j-ii S aye CONTACT EMAIL: C K, 1,, b j,t- C C c.:l/5'LraCcr..+ c-- .-1-t
<br /> 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
<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 Oh pic licaatil n Use Only yis e and I
<br /> comply with the State Contractors Law 18.27 RCW and 296.200 WAC. Cit '-
<br /> PERMIT#:
<br /> Owner/Authorized Agent Signat e Date (Revised 1/11/2019) Page 1-Application
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