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0.11P' ELECTRICAL PERMIT APPLICATION
<br /> CITY OF EVERETT PERMIT SERVICES
<br /> 'Ad Wi3200 CEDAR STREET,EVERETT WA 98201
<br /> (P)425-257-8810 1 FAX 425-257-8857 1(E)everetteps@everettwa.gov I www.everettwa.gov/pernais
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<br /> PROJECT ADDRESS: 1606 Hollow Dale PI Unit D BUILDING AREA: se ft
<br /> PROJECT TYPE: 0 NEW CONSTRUCTION 0 ADDITION 0 TENANT IMPROVMENT 0 REMODEL
<br /> BUILDING USE: D SFR 0 TOWNHOUSE 0 DUPLEX 0 ADU 0 MULTI-FAMILY-#OF UNITS: 0 COMMERCIAL
<br /> CONTRACT PRICE OF WORK:$ 140 ASSOCIATED BUILDING PERMIT If(if applicable):
<br /> DESCRIBE SCOPE OF WORK:
<br /> Low voltage control wiring to t-stat
<br /> THIS INSTALLATION INCLUDES THE FOLLOWING SCOPE:(SELECT ALL THAT APPLY)
<br /> LINE VOLTAGE WORK? 0 NO 0 YES-Select Scope:0 Service 0 Feeder 0 Circuits-ft: 0 Complete Re-wire
<br /> LOW VOLTAGE WORK? 0 NO 0 YES-*of Devices:I
<br /> SELECT SCOPE(REQUIRED):0 Data 0 Intercom El Thermostat 0 Audio 0 Secure Access 0 Security System
<br /> 0 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 /> 0 Other(List All):
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<br /> IS THIS PERMIT EDUCATION,INSTITUTIONAL,HEALTH AND/OR PERSONAL CARE FACILITIES: MI NO ii YES—See Below&Pg.2
<br /> ElBy checking this box,I am stating that I have read and understand all of WAC 29646E1400,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 UCENSURE:ONO :IVES-See Below&Pg,3
<br /> flPursuant 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.
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<br /> OWNER NAME: Robbyn Rich TENANT BUSINESS NAME(If Commercial):
<br /> OWNER MAILING ADDRESS: STREET 1606 Hollow Dale PI Unit D
<br /> c,, Everett STATE WA zip 98204
<br /> OWNER pHoNE:425-879-5544 OWNER EMAIL:rObbyDriCh@gfriail.COM
<br /> CONTRACTOR NAME: Kings Heating Inc
<br /> CONTRACTOR ADDRESS: sTREET18933 HWY 99
<br /> CITY Lynnwood STATE VVA Ap 9f3036
<br /> CONTRACTOR KioNE:425-275-5153 CONTRACTOR EMAIL:MichaelaP©KingsHeating.com
<br /> CONTRACTOR LIC.It(REOLJIRED):KINGSHI850LB ICITY OF EVERETT BUSINESS LIC.ft(REOUIRED):040750
<br /> PRIMARY CONTACT: DOWNER OCONTRACTOR 00THER(Please Specify)
<br /> CONTACT NAME: CONTACT pHoNe:425-879-5544
<br /> Robbyn CONTACT EMAIL:robbynrich@gmailcorn
<br /> AOREEMENT:thereby Oaf*that I have read and examined this application and know the same to be true and correct. Ali provisions of laws and ontinances governing this
<br /> type of work wN be completed whether speci ..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 co i '. . the pe / ;me o construction. That lam authorized by the owner of this property to perform the work for which application is made and!
<br /> ,
<br /> co ply ith th. ate v. . L.,y RCW• d 298,200 WAC. City of Everett Official Use Only
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<br /> 4/2/2019 PERMIT#:
<br /> Owne/A . Il-. , t gnature Date (Revised 1/11/2019) Page 1-Application
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