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ELECTRICAL I LRMIT & FIRE ALARM PEtEMIT APPLICATION <br /> CITY OF EVERE I I PERMIT SERVICES <br /> 3200 CEDAR STREET, EVERETT, WA 98201 <br /> (P)425-257-8810 1 FAX 425-257-8857 j (E)everetteps@everettwa.gov J www.everettwagov/permits <br /> — . <br /> PROJECT SITE INFORMATION <br /> PROJECT ADDRESS:4128 Rucker Ave. Everett, WA 98203 <br /> PROJECT TYPE: ID NEW CONSTRUCTION Ei ADDITION E]TENANT IMPROVMENT El REMODEL <br /> BUILDING USE: El SFR El TOWNHOUSE El DUPLEX 0 ADU 0 MULTI-FAMILY-#OF UNITS El COMMERCIAL <br /> BUILDING AREA: Safeway sq ttl 0,000 <br /> 7-- ELECTRICAL APPLICATION INFORMATION <br /> .......—,-, <br /> CONTRACT PRICE OF WOR pl:$15,000 ASSOCIATED BUILDING PERMIT#(if applicable): <br /> IS THIS LOW VOLTAGE WORK? El NO El YES-#OF DEVICES: <br /> — <br /> IS THIS A FIRE ALARM PERMIT? Z NO I YES-Plans required for review(Both Electrical and Fire Department inspections are required) <br /> DESCRIPTION OF WORK & CODE COMPLIANCE <br /> DESCRIPTION OF WORK: Retrofit <br /> IS THIS PERMIT EDUCATION,INSITUTIONAL,HEALTH AND/OR PERSONAL CARE FACILITIES: grNO 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 /> E 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 OWNER PERFORMING WORK AS THE CONTRACTOR WITHOUT ELECTRICAL LICENSURE:IJNO EYES-See Below&Pg. 3 <br /> 1-- Pursuant to RCW 19.28.261,property owners and leaseholders cannot perform electrical work on buildings for rent,sale,or lease without <br /> the proper electrical licensing and certification,or exemption. By checking this box,I am stating that I have completed and signed the <br /> Seo Page 3 AFFIDAVIT on page 3 of this application to receive an exemption from this licensing/certification requirement, <br /> CONTACT INFORMATION <br /> OWNER NAME Safeway TENANT BUSINESS NAME(If Commercial): Safeway <br /> OWNER MAILING ADDRESS: STREET4128 Rucker Ave. <br /> Everett <br /> sTATE WA zp 98203 <br /> r . <br /> OWNER PHONE: !OWNER EMAIL: <br /> CONTRACTOR NAME:TITTlothy Patil" u jelA v).„,,...__0 c c , _c_.,,....., efo <br /> CONTRACTOR ADDRESS: 5 rREET 17045 SE Royer Rd <br /> (lin,Damascus <br /> STATE OR a,,,97089 <br /> CONTRACTOR PHONE:503-209-4006 'CONTRACTOR EMAIL:well_done _construction@yahoo.C6h1 <br /> iii --- <br /> CONTRACTOR LIC.#(REQUIRED):WELLDEC974DQ ICITY OF EVERETT BUSINESS LIC.#(REQUIRED): r <br /> PRIMARY CONTACT: E OWNER 0 CONTRACTOR Ei OTHER(Please Specify) -qt------) <br /> CONTACT NAME: CONTACT PHONE:503-209-4006 (00( 0(A <br /> Timothy Paul CONTACT EMAIL:well_done_constructiongyahoo.com <br /> AGREEMENT:I hereby certify that I have read anti examined this application and knew the same to be true and correct All provisions of laws and ordinances <br /> governing this 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 <br /> provisions of any other state or local law regulating construction or the performance of construction. That I am authorized by the owner of this property to perform the <br /> work for which application is made and I comply with the State Contractors Law 16,27 RCW and 296.200 WAC <br /> City of Everett Officiai Use Only <br /> PERMIT# <br /> I <br /> 6') 2. ( ( 1 <br /> 12-18-2018 - <br /> Owner/AuthorizedAnt Signature Date (Revised 11/5/2018) <br />