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ELECTRICAL PERK/411T APPLIICATIION <br /> CITY OF EVERETT PERMIT SERVICES <br /> 'i 3200 CEDAR STREET,EVERETT,WA 98201 <br /> E7E7/7 (P)425-257-8810 I FAX 425-257-8857 I(E)everetteps@everettwa.gov I www.everettwa.gov/permits <br /> ---- <br /> PROJECT ADDRESS:_ ._ 0 . C Il \ �' <br /> �i y �UILDING AREA: sq ft <br /> 1 <br /> (PROJECT TYPE: 0 NEW CONSTRUCTION 0 ADDITION 0 TENANT IMPROVMENT 0 REMODEL <br /> 'BUILDING USE: 0 SFR 0 TOWNHOUSE 0 DUPLEX 0 ADU 0 MULTI-FAMILY-#OF UNITS: 0 COMMERCIAL <br /> . _NTR <br /> f LECTR CAL APPLICATION INFORMA IOa N az. DESCRIPTION Or �>�7�EMC - _ i <br /> !CONTRACT PRICE OF WORK:$ 'ASSOCIAT`E,D-BUILDING PERMIT#(if applicable): <br /> DESCRIBE SCOPE OF WORK: AC,.e r �`(libt-l* <br /> I <br /> i <br /> 'THIS INSTALLATION INCLUDES THE FOLLO SCOPE: (SELECT ALL THAT APPLY) <br /> I LINE VOLTAGE WORK? 0 NO YES Select Scope: <br /> U Service 0 Feeder 0 Circuits-#: 1 0 Complete Re-wire <br /> I LOW VOLTAGE WORK? 0 NO 0 YES-#of Devices: <br /> SELECT SCOPE(REQUIRED): <br /> 0 Data 0 Intercom ©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): -"- <br /> _ C--------CtDE C MPL(AE `E • �•--�-�• ..w______,.__. , <br /> IS THIS PERMIT EDUCATION,INSTITUTIONAL, HEALTH AND/OR PERSONAL CARE FACILITIES: O <br /> LI S -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 /> 0 of this application(see next page),AND Plan Review is NOT required because I meet all of the following sub se 'ons that do not <br /> See Page 2 require Plan Review. <br /> ARE YOU AN OWNER PERFORMING WORK AS THE CONTRACTOR WITHOUT ELECTRICAL LICENSURE: NO DYES-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 /> j p_ 1 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 Ervogni�"E°E fel <br /> OWNER NAME: �.. c `A -0M `,ki TENANT BUSINESS NAME(If Commercial): <br /> � <br /> 'OWNER MAILING ADDRESS: STREET 1 C9 Y Pr <br /> 317056.1466 , <br /> i , <br /> • <br /> CITY i© , 4 STATE y ZIP - .�) <br /> OWNER PHONE: �7t(� <br /> ���/`�,�,/��� . * 1 Cl OWNER EMAIL <br /> CONTRACTOR NAME: , �, 'eC..l I--4C <br /> CONTRACTOR ADDRESS: STREET 'C� /v' , (J��,j�� <br /> STATE ZIP 6 I V . <br /> CITY <br /> CONTRACTOR PHONE: . #6 - i, • <br /> O I,I' ONTRACTOR EMAIL: <br /> CONTRACTOR LIC. _ D ' CITY OF EVERETT BUSINESS LIC.#(REQUIRED) <br /> PRIMARY CONTAC C Or,. R ❑ ONTRACTOR ❑OTHER(Please Specify) <br /> . CONTACT PHONE: 9 - ' • -or —21 <br /> 'CONTACT A1 .ME: I <br /> .,, _ CONTACT EMAIL: <br /> _ <br /> AGREE T.'Iv <br /> -+" certify that I ha .;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 1, •leted whether •ecified 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 regulatin:on.truction or the/performance of construction. That f am authorized by the owner of this property to perform the wtr for <br /> Ewhrett hich epic ati ion Use made and I <br /> comply with th= • ae .ntractors w 18.27 RCW and 296.200 WAC. CiPERMIT#: <br /> EIS - d \L <br /> 'swner/A ori`srwe'tSignature Date (Revised 1/11/2019) Page 1-Application <br />