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01/'08 2007 04: 47 14257751'
<br /> ACTIVE ENGINEERING PAGE 02!02
<br /> ELECTRICAL PERMIT APPLICATION
<br /> CITY OF EVERETT PERMIT SERVICES
<br /> s• 3200 CEDAR STREET,
<br /> (P).425-257-8810 I FAX 420.257-8857 EVERETT,WA 98201
<br /> `;?r-• .:.w.; v re ver kttva.gov� www,evcre
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<br /> PROJECT ADDRESS: ? � -='�"�^r;.c:k :�':°r�•:i:,e:.:-::,:.; :'Jf;•r:--`''r"'r' ;:''" ��:":_�:;;u�w. .,>:r
<br /> ESS: �j JZI /g�1rc41
<br /> PROJECT TYPE: NEW CONSTRUCTION ❑ADDITION .TENANT IMPRO ESUILDING AREA: ^� COQ _sq ft
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<br /> AMILY
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<br /> LI REMODEL USE: ❑SFR ❑ TOWNHOUSE ❑DUPLEX ADUMULTI-F NIT
<br /> s �.� COMMERCIAL
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<br /> CONTRACT PRICE OF WORK:3 f 9-00- a`' ASSOCIATED BUILDING PERMIT#(if applicable):
<br /> DESCRIBE SCOPE OF WORK; A /4z,--;-,, - -3
<br /> THIS INSTALLATION INCLUDES THE FOLLOWING SCOPE: (SELECT ALL.THAT APPLY)
<br /> LINE VOLTAGE WORK? 0 NO BYES-Select Scope:p ❑Service ❑ Feeder 1:KCircuits-#: 3 17 Complete Re-wire
<br /> LOW VOLTAGE WORK? XNO El YES-#of Devices;
<br /> SELECT SCOPE (REQUIRED): ❑ Data ❑Intercom 0 Thermostat ❑Audio ❑Secure Access ❑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):
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<br /> IS THIS PERMIT " uTm �.. dr %!F ,:•_si; L.:G a7 a%s ` w a. „
<br /> �,SeeiBelow'_. Ee +i..ito:
<br /> EDUCATION,INSTITUTIONAL,HEALTH AND/OR PERSONAL CARE FACILITIES: <�rNO 1�5~YES•-See Below&Pg.2
<br /> F 1 By checking this box, I am stating that I have read and understand all of WAC 296-46R-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: NO EYES-See Below& Pg. 3
<br /> 1 l Pursuant to RCW 19.26.261,property owners and leaseholders cannot perform electrical work on buildings for rent, sale,or lease
<br /> 1 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 /> '..k:.-�a :_' 'rE::.n.:..;:_ .,-•e.;,..
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<br /> -
<br /> OWNER NAME: Jep-�, i b.( I$ f,� TENANT BUSINESS NAME If Commercial : Fd `.'. 6.-(-- 0 Of--
<br /> OWNER MAILING ADDRESS: S7R(ET P o , 64.r 9 U 3 -
<br /> CIN 61 kir-', _ STAT WA , k S-7
<br /> OWNER PHONE: OWNER EMAIL:
<br /> CONTRACTOR NAME: fir-t-i-Ve- Cf 1 I PI�C✓r vi
<br /> CONTRACTOR ADDRESS: STREET tD 0 5 Z O0
<br /> --� .514- SvNi
<br /> CT,' ni10(04�
<br /> STATE ZIP IIIA 36
<br /> —/
<br /> CONTRACTOR PHONE; 20 — (S��3 c !'CONTRACTOR EMAIL:
<br /> CONTRACTOR LIC.#REQUIRED : l' w G11'>Cf Gi 1/ ClC-f7,/�,e�G 1,1CGi:rlcl .,-t=f
<br /> laM ���CITY OF EVERETT BUSINESS LIC. • REQUIRED): y
<br /> PRIMARY CONTACT: ❑OWNER IgCONTRACTOR ' !OTHER(Please Specify)
<br /> CONTACT NAME. CONTACT PHONE; 17-4
<br /> CONTACT EMAIL: CIC 0 b e
<br /> AGEMENT I hereby certify that/have read and examined tills application and know the tame to be trvo C�✓G C� I o r�i'N ' h h
<br /> type of work will Ac cornpletect Whether specified herein or not. The grantingof 4noand COI tho y t Pro eie or or cancel
<br /> the r vt/ (ons o any other
<br /> g ata
<br /> local law regulating construct/on or the perforrrlaRCe of construction. That I am authorized by theownerof thispresume to give
<br /> dutha per vrm the
<br /> orkfor the
<br /> provisions of anyOtitersfate or
<br /> comply with the Statg Contractor Law 18,27 RCW and 296.200 W4C, property Perform tl1®work for which application 1e made and!
<br /> al,i,—
<br /> CI of Evgn=tt Officialoily_
<br /> PERMIT#:
<br /> C--‘ 3/1// E I b — -6T1---.
<br /> owner/Authorized Agent Signature Date
<br /> (Rew;ed 1/11/2019) Page 1-Application
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