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ELECTRICAL PERMIT APPLICATION
<br /> OLTCITY OF EVERETT PERMIT SERVICES
<br /> 3200 CEDAR STREET,EVERETT,WA 98201
<br /> (P)425-257-8810 I FAX 425-257-8857 I(E)everetteps@everettwa.gov I wrrw.everetiwa.gov/permits
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<br /> PROJECTf ADDRESS:. /4 rgreen(4au BUILDING AREA: sq ft
<br /> PROJECT TYPE: ❑ NEW CONSTRUCTION ❑ADDITION CV TENANT IMPROVMENT ❑ REMODEL
<br /> BUILDING USE: ❑SFR ❑ TOWNHOUSE El DUPLEX ❑ADU ❑ MULTI-FAMILY-#OF UNITS: EOMMERCIAL
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<br /> CONTRACT PRICE OF WORK:$ 1p©D, Q1} ASSOCIATED BUILDING PERMIT#(if applicable):
<br /> DESCRIBE SCOPE OF WORK: I/24eet di/G*1414S 4274 W,Pre, / 7J/ f/
<br /> THIS INSTALLATION INCLUDES THE FOLLOWING SCOPE: (SELECT ALL THAT APP-LY))
<br /> I�Y
<br /> LINE VOLTAGE WORK? ❑ NO ES-Select Scope:❑ Service ❑ Feeder Circuits-#:i ❑ Complete Re-wire
<br /> LOW VOLTAGE WORK? ❑ NO ❑YES-#of Devices:
<br /> SELECT SCOPE(REQUIRED): ❑ Data ❑Intercom ❑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):
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<br /> IS THIS PERMIT EDUCATION,INSTITUTIONAL,HEALTH AND/OR PERSONAL CARE FACILITIES: X 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: 3}5(0-
<br /> i EYES-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.
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<br /> OWNER NAME: TENANT BUSINESS NAME(If Commercial): 1401.6 �"Ileac clever I
<br /> OWNER MAILING ADDRESS: STREE Gjige d/•8 1fj�pJ
<br /> CITY STATE ZIP
<br /> OWNER PHONE: OWNER EMAIL:
<br /> CONTRACTOR NAME: 7 7 P7—� (� /4C
<br /> CONTRACTOR ADDRESS: AA45I 4 f/W41/j,^J /11 A F ?d
<br /> idCITY f) STATE 9M76
<br /> CONTRACTOR PHON 0567a 7(p CONTRACTOR EMAIL:/ I C ,/ // 1
<br /> CONTRACTOR LIC aF. Z� / - CITY OF EVERETT BUSINESS LEC.#(REQUIRI �'`.' a
<br /> PRIMARY CONTACT: DOWNER LYGONTRACTOR
<br /> ❑OTHER(Please Specify)
<br /> CONTACT NAME:, CONTACT PHONE: 1a�5/e/ � `��
<br /> ,� l� �E/ � CONTACT EMAIL: �II�iPi
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<br /> AGREEMENT.!hereby cerGly that t have read and examined this application and know the same to be true and correct. All provisto1 laws an 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!
<br /> comply with the State Contractors Law 18.27 RCW and 296.200 WAC. City of Everett Official Use Only
<br /> PERMIT#:
<br /> E cl -b-71
<br /> Owner/Au horized Agen ignature Date (Revised 1/11/2019) Page 1-Application
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