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ELECTRICAL PERMIT APPL.JATION
<br /> CITY OF EVERETT PERMIT SERVICES
<br /> 3200 CEDAR STREET, EVERETT,WA 98201
<br /> (P)425-257-8810 1 FAX 425-257-8857 1(E)everetteps@everettwa.gov 1 www.everettwa.gov/permits
<br /> PROJECT SITE INFORMATION
<br /> PROJECT ADDRESS: u t-ba Vv -Jo '1*.� ft r� UILDING AREA: sq ft
<br /> PROJECT TYPE: El NEW CONSTRUCTION C'd ADDITION TENANT IMPROVMENT ❑ REMODEL
<br /> BUILDING USE: [II SFR ❑TOWNHOUSE ❑ DUPLEX ❑ADU [7MULTI-FAMILY-#OF UNITS: 7•.-1.."'
<br /> COMMERCIAL
<br /> ELECTRICAL APPLICATION INFORMATION & DESCRIPTION OF WORK
<br /> CONTRACT PRICE OF WORK: $ 50v • 0 O ASSOCIATED BUILDING PERMIT#(if applicable):
<br /> DESCRIBE SCOPE OF WORK: rty\e CA Qr,X,:;Vi yn 3 v\cCt, au (,R ,,,hAtk, A,
<br /> „,,,,,.., v,...9
<br /> \,,,,,,,,v„..„
<br /> THIS INSTALLATION INCLUDES THE FOLLOWING SCOPE: (SELECT ALL THAT APPLY)
<br /> LINE VOLTAGE WORK? NO ❑ YES-Select Scope: C Service El Feeder
<br /> ❑ Circuits-#: 17 Complete Re-wire
<br /> LOW VOLTAGE WORK? NO ❑ YES-#of Devices:
<br /> SELECT SCOPE(REQUIRED): ❑ Data ❑ Intercom ❑ Thermostat ❑Audio ❑ Secure Access
<br /> ❑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):
<br /> CODE COMPLIANCE
<br /> IS THIS PERMIT EDUCATION, INSTITUTIONAL,HEALTH AND/OR PERSONAL CARE FACILITIES: ❑ NO ❑ YES--See Below&Pg. 2
<br /> .,,"^�J j - 1 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 LICENSUIZEI, NO 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.
<br /> CONTACT INFORMATION
<br /> OWNER NAME: TENANT BUSINESS NAME(If Commercial):(c*1 tAiwpit. Iii e!A')
<br /> OWNER MAILING ADDRESS: STREET j (4176 Lt e.,.-c c..ieT, \APO`�`.
<br /> CITY CV-CY' •-tit. STATE Or 10t. ZIP l Sa0.3
<br /> OWNER PHONE: - .. 3- OWNER EMAIL:C. 1v , tl Wad 4.e.. • J•i ` 4 AI "1111 • ti t
<br /> CONTRACTOR NAME: St,A. ZIA C 04 I31 f L
<br /> CONTRACTOR ADDRESS: STREET . •
<br /> a....‘4 Q0 r ?L 'S
<br /> CITY e.-� 1--” STATE \IQ ZIP Qt 1I' i
<br /> CONTRACTOR PHONE: , 0 `;at, • '' 4„. CONTRACTOR EMAIL: .1), .• .4, * AA - • * la`M ik.e
<br /> gi
<br /> CONTRACTOR LIC,#(REQUIRED);5l T is%(1,4,70R,bR, CITY OF EVERETT BUSINESS LIC.#(REQUIRED): $
<br /> PRIMARY CONTACT: 'DOWNER CONTRACTOR DOTHER(Please Specify) Sli tgliffe,It'• ti~ ,VOA
<br /> CONTACT NAME: CONTACT PHONE:t__E 1,,1 --r t 5 b ) i s r Asa 1,4
<br /> �U�h� L-Uh�ILyr, +~lit it;tkr' CONTACT EMAIL: [tVu,f'V) S -On
<br /> Lcl nttI ,.Ckorm
<br /> AGREEMENT'I hereby certify that I have read and examined this application and know the same to be true nd correct All prtwisions 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 the State Contractors Law 18,27 RCW and 296.200 WAC. City of Everett Official Use Only
<br /> PERMIT#:
<br /> 1.661
<br /> E } Ot r3t--- - 1
<br /> caner/Authorized Age ig • re I Date (Revised 1/11/2019) Page 1-Application
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