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<br /> Lil EL ..:TRICAL PERMIT APPLICATIIII
<br /> EVERETT CITY OF EVERETT PERMIT SERVICES
<br /> 3200 CEDAR STREET,EVERETT,WA 98201
<br /> WASHINGTON (P)425-257-8810 l FAX 425-257-8857 1(E)everetteps@everettwa.gov I www.everettwa.gov/permits
<br /> ..;,„ PROJECT SITE INFORMATION
<br /> PROJECT ADDRESS: (7 (� \ e,r-IPZ,25\ ) BUILDING AREA: X 'k(,. sq ft
<br /> PROJECT TYPE: ❑NEW CONSTRUCTION El ADDITION ❑TENANT IMPROVMENT N REMODEL
<br /> BUILDING USE: 0 SFR El TOWNHOUSE ❑DUPLEX El ADU El MULTI-FAMILY-#OF UNITS: ►'4 COMMERCIAL
<br /> 'ELECTRICAL APPLICATION INFORMATION S DESCRIPTION OF WORK
<br /> CONTRACT PRICE OF WORK:$ Qi''-'`"'t-)-:ie ASSOCIATED BUILDING PERMIT#(if applicable):
<br /> �
<br /> DESCRIBE SCOPE OF WORK: '-'),,...^0c0,, C,,( `> (NC , 01\0, 9c4,� y.:-.\ `'5L11-U\
<br /> THIS INSTALLATION INCLUDES'THE FOLLOWING SCOPE:(SELECT ALL THAT APPLY)
<br /> LINE VOLTAGE WORK? El NO ❑YES-Select Scope: ❑Service ❑Feeder ❑Circuits-#: ❑Complete Re-wire
<br /> LOW VOLTAGE WORK? ❑NO Nr�YES.#of Devices: l'?�. .°
<br /> .,
<br /> SELECT SCOPE(REQUIRED): [Data L^J Intercom El Thermostat ❑Audio El Secure Access El Security System
<br /> El Fire Alarm-Installations under this permit only include electrical wiring rough-in of the system.Art additional
<br /> Fire Alarm Permit is required for review of device location and installation approval.
<br /> ❑Other(List All):
<br /> ', C.ODE COMPUANC ;..::.S ..... ,.,,
<br /> IS THIS PERMIT EDUCATION,INSTITUTIONAL,HEALTH AND/OR PERSONAL CARE FACILITIES: E NO El 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: NO DYES-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.
<br /> CONT w...... .NFORM1TjN
<br /> OWNER NAME: TENANT BUSINESS NAME(If Commercial): C 1 3 ';
<br /> OWNER MAILING ADDRESS: STREET
<br /> CRY STATE ZIP
<br /> OWNER PHONE: .-� OWNER EMAIL: y
<br /> CONTRACTOR NAME: N j'`+3 t j L i L -
<br /> / I i a\ �)
<br /> CONTRACTOR ADDRESS: STREET ' "tn �., t'U , Si .
<br /> „,nsy:-+
<br /> CITY V A-A STATE ry+,ZIP 1 ,J�,9
<br /> CONTRACTOR PHONE: D` ',i�'v . CONTRACTOR EMAIL: i fys, \LA)iti. b
<br /> CONTRACTOR LIC.#(REQUIRED): NWTELTL892R0 CITY OF EVERETT BUSINESS LIC.#(REQUIRED): 55567
<br /> PRIMARY CONTACT: DOWNER r CONTRACTOR ❑OTHER(Please Specify)
<br /> CONTACT NAME: ` � CONTACT PHONE:c,,,,,\' ,•ted{ ,Lko "3-
<br /> �-'� � /t'C. . e,\ c<, '�, CONTACT EMAIL: , ,,,,, a ` , .,c v i,,°a.X,,s 'ry.,,, , �`k
<br /> AGREEMENT I hereby certify that I 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 for which application is made and I
<br /> comply with theSlat nfractors Law 18.27 RCW and 29..200 WAC. City of Everett Official Use Only
<br /> PERMIT#:
<br /> Owner/Authorized Agent Si a re Date (Revised 1/11/2019) Page 1-Application
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