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t <br /> mei <br /> ELECTRICAL PERMIT APPUCAT[ON <br /> CITY OF EVERETT PERMIT SERVICES <br /> EVERETT 3200 CEDAR STREET,EVERETT,WA 98201 <br /> (P)425-257-8810 I FAX 425-257-8857 I(E)everetteps@everettwa.gov I www.everettwa.gov/permits <br /> WASHINGTON <br /> 1 1� <br /> PROJECT SITE INFORMATION <br /> PROJECT ADDRESS❑',"J ;"� T, \ e `ji BUILDING AREA: sq ft <br /> PROJECT TYPE: ❑ NEW CONSTRUCTION ❑ADDITION ri TENANT IMPROVMENT ❑ REMODEL <br /> BUILDING USE: ❑SFR ❑ TOWNHOUSE El DUPLEX ❑ADU ❑ MULTI-FAMILY-#OF UNITS: COMMERCIAL <br /> ELECTRICAL APPLICATION INFORMATIONig,'DESCRIPTIONOFWORK <br /> CONTRACT PRICE OF WORK:$ ,.j,,in too ASSOCIATED BUILDING PERMIT#(if applicable): A\0101 `DO <br /> DESCRIBE SCOPE OF WORK.`'III4 ,A ,i / (, Q UM �,c <br /> Kv-.D 0 .0( '-n k ! SUM- u� *5 _L2) 1 <br /> 0v <br /> THIS INSTALLATION INCLUDES THE FOLLOWING SCOPE: (SELECT ALL THAT APPLY) <br /> LINE VOLTAGE WORK? ❑AO14 <br /> YES-Select Scope: ElService CIFeeder n Circuits-#:6 ElComplete Re-wire <br /> LOW VOLTAGE WORK? 5 NO ❑YES-#of Devices: <br /> SELECT SCOPE(REQUIRED): <br /> ❑ Data El Intercom ❑Thermostat ❑Audio ❑ Secure Access El 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: El 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-906,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:VNO 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 /> !, menet--. <br /> CONTACT INFORMATION <br /> ;t4 ? <br /> OWNER NAME: <1.4. t/tA." TENANT BUSINESS NAME� (If Commercial): <br /> OWNER MAILING ADDRESS: STREET 11� -"' 1 57 <br /> 6ka ` tt,[/ r/ _ D,)(3--0 (��/�� <br /> CITY MALI.' C( STATE A ZIP �N <br /> OWNER PHONE: OWNER <br /> EMAIL: ti. <br /> CONTRACTOR NAME: W.-bo 04k1,121WAWilt— <br /> CONTRACTOR ADDRESS: STREET (20 936x 14,111572 qq�' ^ <br /> CITY 50416 STATE ZIP ofw <br /> ; �� ,,nn�1 a��f u� � 21a� <br /> CONTRACTOR PHON : D (Rey RWO CONTRACTOR EMAIL: wa'i.�(- * (DI <br /> CONTRACTOR LIC.#(RE UIRED): LP.fern CITY OF EVERETT BUSINESS LIC.#(REQUIRED) <br /> PRIMARY CONTACT: DOWNER "in CONTRACTOR ❑OTHER(Please Specify) <br /> CONTACT NAME: CONTACT PHONE:) 0; 11-4(41. <br /> - � ���a11I <br /> '�yn4 �� ���(������j� CONTACT EMAIL: Air <br /> kkeic,co ft <br /> AGREEMENT:I hereby certifytithat I have read and examined this application and know the same to be true and correct. All provisiolfe"of laws and ordinances governing this <br /> type of work will be completed whether spec' erein 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 regele3ting construction or the p ormance of construction. That 1 am authorized by the owner of this property to perform the work for which application is made and I <br /> comply with the j4tate Contractors La 18.27 RCW and 296.200 WAC. City of Everett Official Use Only <br /> PERMIT#: <br /> ir/At4"---1. <br /> uut _E � � D U• Age Si - u e Date (Revised 1/11/2019) age 1-Application <br />