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<br /> - ` ELECTRICAL PERMIT APPLICATION
<br /> CITY OF EVERETT PERMIT SERVICES
<br /> EVERETT 3200 CEDAR STREET, EVERETT,WA 98201
<br /> WASHINGTON (P)425-257-8810 I FAX 425-257-8857 I(E)everetteps@everettwa.gov I www.everettwa.gov/permits
<br /> PROJECT SITE INFORMATION
<br /> PROJECT ADDRESS: C z 7 0 6 v Fief!-P-,-, t__/;` e"BUILDING AREA: ZX -' sq ft
<br /> PROJECT TYPE: ❑ NEW CONSTRUCTION ❑ADDITION LJ TENANT IMPROVMENT ❑ REMODEL
<br /> BUILDING USE: ❑SFR ❑ TOWNHOUSE ❑ DUPLEX ❑ADU ❑ MULTI-FAMILY-#OF UNITS: ❑ COMMERCIAL
<br /> ELECTRICAL APPLICATIONINFORMATION & DESCRIPTION OFWORK
<br /> CONTRACT PRICE OF WORK:$ - ASSOCIATED BUILDING PERMIT#(if applicable):
<br /> DESCRIBE SCOPE OF WORK: /. „ ; -_ ,.(r> t ! • 1/9 c-c .J,r Vi-, ),.//-1>,-) _4-tic c-,,__j `] p t'-'c
<br /> �4, (, T
<br /> THIS INSTALLATION INCLUDES THE FOLLOWING SCOPE: (SELECT ALL THAT APPLY)
<br /> LINE VOLTAGE WORK? ❑ NO ❑YES-Select Scope: El Service ❑ Feeder ❑ Circuits-#: El Complete Re-wire
<br /> LOW VOLTAGE WORK? ❑ NO ❑YES-#of Devices:
<br /> SELECT SCOPE(REQUIRED): El 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): �9(7 c ,..._• "! t� ,,,,,
<br /> CODE COMPLIANCE -
<br /> IS THIS PERMIT EDUCATION, INSTITUTIONAL, HEALTH AND/OR PERSONAL CARE FACILITIES: ❑ 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: ENO 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: .5--r-__C Li_,,_ TENANT BUSINESS NAME(If Commercial): 54.3,...-E--
<br /> OWNER
<br /> .- fOWNER MAILING ADDRESS: STREET �F// t
<br /> CITY _1� /V! -F" STATE LamC . ZIP //3
<br /> OWNER PHONE: OWNER EMAIL:
<br /> CONTRACTOR NAME: 5:Aq-7. 5-11 /c-., r✓4-in J
<br /> CONTRACTOR ADDRESS: STREET /-��/ C-' 7 5 r z-J 'i---- - l�v.-..c1 Ll/� t
<br /> errY 1 l/ •C�- _ l STATE [,� ZIP c g 7 97
<br /> CONTRACTOR PHONE:2-(75 7? jig' 2 Z CONTRACTOR EMAIL: tptel r k N(D 5,,- r .Jt,/0 f(.r. (c',-.."-
<br /> CONTRACTOR
<br /> ^^CONTRACTOR LIC.#(REQUIRED):5 ,44" ,'5� �5IK .7 CITY OF EVERETT BUSINESS LIC.#(REQUIRED):
<br /> pc -
<br /> PRIMARY CONTACT: DOWNER CONTRACTOR ['OTHER(Please Specify)
<br /> CONTACT NAME: CONTACT PHONE: 2$1:5"-- 6 6 i' 7 ST
<br /> t CONTACT EMAIL:
<br /> roe?I'L L,g,)s,,,,�:fin/L I . ((> 1,,,,_--._
<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 constru tion. 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 tate Contractors Law 18.27 RCW and 296. 0 WAC. City of Everett Official Use Only
<br /> � PERMIT#:
<br /> A---1-1/ (
<br /> z4gf7s�� E 01OC- 1 C (61
<br /> Ownef/Auth.rized Agent Signature Date (Revised 1/11/2019) Page 1-Application
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