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111 imon <br /> ELECTRICAL PERMIT APPLICATION <br /> CITY OF EVERETT PERMIT SERVICES <br /> EVERETT 3200 CEDAR STREET,EVERETT,WA 98201 <br /> WASHINGTON (P)425-257-8810 1 FAX 425-257-8857 1(E)everetteps@everettwa.gov I www.everettwa.gov/permits <br /> PROJECT SITE INFORMATION .'. <br /> PROJECT ADDRESS: S I Eu e(a fee n W n Y"• BUILDING AREA: sq ft <br /> PROJECT TYPE: ❑ NEW CONSTRUCTION ADDITION kTENANT IMPROVMENT ❑ REMODEL <br /> BUILDING USE: ❑SFR ❑TOWNHOUSE ❑ DUPLEX ❑ADU ❑ MULTI-FAMILY-#OF UNITS: $COMMERCIAL <br /> ELECTRICAL APPLICATION INFORMATION & DESCRIPTION OF WORK <br /> CONTRACT PRICE OF WORK:$ MO y ©0 ASSOCIATED BUILDING PERMIT#(if applicable): <br /> DESCRIBE SCOPE OF WORK: tf) Sh4-(f 5 y 5+E Cult/ G/M7 e-1749 y 57?M-5- <br /> THIS INSTALLATION INCLUDES THE FOLLOWING SCOPE: (SELECT ALL THAT APPLY) <br /> LINE VOLTAGE WORK? ❑ NO YES-Select ScopeE[ <br /> : Se -Feed_er E Circuits-#: ❑ Complete Re-wire <br /> Q <br /> LOW VOLTAGE WORK? NO 1YES-#of Devices: 5 1 <br /> SELECT SCOPE(REQUIRED): room` _EJ hermostat LJ Audio ❑ Secure Access is.g4 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 /> ElOther(List All): CO(_. Vne IN 5L fes'k'c\ <br /> CODE COMPLIANCE':..: <br /> IS THIS PERMIT EDUCATION,INSTITUTIONAL,HEALTH AND/OR PERSONAL CARE FACILITIES: [ 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:KNO 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 /> CONTACT INFORMATION ` ... . .. <br /> OWNER NAME: Tom m B€R€ TENANT BUSINESS NAME(If Commercial): Ve e � 1\)C: <br /> OWNER MAILING ADDRESS: STREET <br /> CITY STATE ZIP <br /> OWNER PHONE: OWNER EMAIL: <br /> CONTRACTOR NAME: AL I C k 6(.�c's v 3 e, <br /> CONTRACTOR ADDRESS: STREET P0 6 Q 1x 13 cl 3 <br /> CITY 1 V r'�iq*5 )( 1Q.. STATE, W 7 ZIP a. [D <br /> CONTRACTOR PHONEq s37?'-77 33 CONTRACTOR EMAIL:� D(_ 4Ct t 1�.5 S X115 L t ( t <br /> CONTRACTOR LIC.#(REQUIRED) 4Ll.T sz3bb CITY OF EVERETT BUSINESS LIC.#(REQUIRED) O `r 5-2 .... <br /> PRIMARY CONTACT: DOWNER ECONTRACTOR ❑OTHER(Please Specify) <br /> CONTACT NAME: r CONTACT PHONE: (� 4 A 5 Qe/�(o•- 1.51 ( <br /> 3ETN{ Qu ss e � CONTACT EMAIL: �1 [/�`$:N s7 S '`E'II1-S ne, 4- <br /> AGREEMENT::t hereby certify that I have read and examined this application and know t same to be true and correct. All pfovisions 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 t .erformance 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 thy ate Cont actors - 18.27 RCW and 29-. Or WAC. City of Everett Official Use Only <br /> PERMIT#: <br /> / E tct oS - oC0 <br /> iv/ <br /> Owner/ ut,• z•.Agent Signature D (Revised 1/11/2019) Page 1-Application <br />