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13 <br />ELECTRICAL PERMIT APB.-ATION <br />CITY OF EVERETT PERMIT SERVIUtb <br />3200 CEDAR STREET, EVERETT, WA 98201 <br />(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: c(LI 3o tlK!ri reed h'`L <br />BUILDING AREA: sq ft <br />PROJECT TYPE: ❑ NEW CONSTRUCTION ❑ ADDITION © TENANT IMPROVMENT ❑ REMODEL <br />BUILDING USE: ❑ SFR ❑ TOWNHOUSE ❑ DUPLEX ❑ ADU ❑ MULTI -FAMILY - # OF UNITS: 0 COMMERCIAL <br />ELECTRICAL APPLICATION INFORMATION & DESCRIPTION OF WORK <br />CONTRACT PRICE OF WORK: $ 3 Cry <br />ASSOCIA T ED BUILDING PERMIT # (if applicable): <br />DESCRIBE SCOPE OF WORK: cXc��2 Z ��., J�i t�� OA,2 <br />THIS INSTALLATION INCLUDES THE FOLLOWING SCOPE: (SELECT ALL THAT APPLY) <br />LINE VOLTAGE WORK? 2q NO ❑ YES - Select Scope: ❑ Service ❑ Feeder ❑ Circuits-#: ❑ Complete Re -wire <br />LOW VOLTAGE WORK? ❑ NO YES- # of Devices: 2— <br />SELECT SCOPE (REQUIRED): ❑ Data ❑ Intercom ® 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): <br />CODE COMPLIANCE <br />IS THIS PERMIT EDUCATION, INSTITUTIONAL, HEALTH AND/OR PERSONAL CARE FACILITIES: D NO X1 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: 7NO []YES -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): :LAPct a'•CYS <br />OWNER MAILING ADDRESS: STREET <br />CITY `L� � STATE i t ZIP C1810 <br />OWNER PHONE: <br />OWNER EMAIL: <br />I <br />CONTRACTOR NAME: C FM He0' k'f(- LVj C.'e 11 <br />CONTRACTOR ADDRESS: STREET � j( 3.zv <br />y r/'� <br />k- a. CITY I r (, STATE ZIP <br />CONTRACTOR PHONE:y25-Ci2.1 - IZg3 <br />CONTRACTOR EMAIL: _Jzuc ov C FR— 0 YK e _ cc -)A" - <br />CONTRACTOR LIC. #(REQUIRED):C rM RE r' IN'( <br />CITY OF EVERETT BUSINESS LIC. #(REQUIRED): <br />PRIMARY CONTACT: ❑OWNER ©CONTRACTOR ❑OTHER (Please Specify) <br />CONTACT NAME: <br />.-Tci 24 ��(J(er <br />CONTACT PHONE: `1 ZS _ tv- Z13 <br />CONTACT EMAIL: yeM N �r�C VA <br />AGREEMENT. I hereby certify that l have read and examined this application and know the same to bb 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/ 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 Oniv <br />PERMIT #: <br />z" 6/Y- 17-1 E o4 <br />Owner Author' ed gent Signature Date (Revised 1/1112019) Page 1-Application <br />G <br />