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ELECTRICAL P-RMIT & FIRE ALARM PMIT APPLICATION
<br /> CITY OF EVERETT PERMIT SERVICES
<br /> -#' ' #1111:411
<br /> 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
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<br /> PROJECT ADDRESS: _ it 4100 C/, ✓ ltk (-JAY
<br /> PROJECT TYPE:. NEW CONSTRUCTION 0 ADDITION
<br /> 0 TENANT IMPROVMENT 0 REMODEL
<br /> BUILDING USE: 0 SFR 0 TOWNHOUSE 0 DUPLEX 0 ADU 0 MULTI-FAMILY-#OF UNITS: 0 COMMERCIAL
<br /> BUILDING AREA: sq ft
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<br /> CONTRACT PRICE OF WORK:$ ASSOCIATED BUILDING PERMIT#(if applicable):TS IP,000 — q/
<br /> IS THIS LOW VOLTAGE WORK? -121 NO 0 YES-#OF DEVICES:
<br /> IS THIS A FIRE ALARM PERMIT? Ai NO 0 YES-Plans required for review(Both Electrical and Fire Department inspections are required)
<br /> A QES RIPT O SOF.W�,1RK��&+Ceitit tOliiI1R . A V' M z , �3 V,
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<br /> DESCRIPTION OF WORK: Cpm A ,(1-GI AL (71&. CPAIt51, Sti -I V-)
<br /> IS THIS PERMIT EDUCATION,INSTITUTIONAL,HEALTH AND/OR PERSONAL CARE FACILITIES: pi NO 0 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: 0NO OYES-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 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 /> See Page 3 AFFIDAVIT on page 3 of this application to receive an exemption from this licensing/certification requirement.
<br /> CONTACT INFORMATION
<br /> OWNER NAME: v '1"6- TENANT BUSINESS NAME� yZ6'r (. ,tia '�'�'"J J' (If Commercial): &Raj 9/Avl-PlLA
<br /> OWNER MAILING ADDRESS: STREET
<br /> CITY STATE ZIP
<br /> OWNER PHONE: OWNER EMAIL:
<br /> CONTRACTOR NAME: l,N......65- .L. I. I,N(--, 'r
<br /> CONTRACTOR ADDRESS: STREET ( 6' ,3,77 1 K,�,C1 Civ S-11--
<br /> CITY 06/N44Z STATE (AA ZIP Ms 0
<br /> CONTRACTOR PHONE:?ZS-40o 7-15a7CONTRACTOR EMAIL: jtt A.A..)4 6 I,JArtiS Qur ./G,, Gs:),,1/i
<br /> CONTRACTOR LIC.#(REQUIRED): )D6 IJ.NIt1"}I / CITY OF EVERETT BUSINESS LIC.#(REQUIRED): 3-3a 3 S
<br /> PRIMARY CONTACT: 0 OWNER CONTRACTOR 0 OTHER(Please Specify) 151,4 A✓`/ PCLS
<br /> CONTACT NAME: CONTACT PHONE: )4//2 S 5 0 L —5003
<br /> TjtkAli .1.146 CONTACT EMAIL:
<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
<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 of s state o ocal 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 appl - ion i• ade and I comply with the State Contractors Law 18.27 RCW and 296.200 WAC.
<br /> City of Everett Official Use Only
<br /> //- PERMIT#
<br /> �� l 11 l ' C isoe -11.
<br /> • er/Authoriz 7 gent Signature Date (Revised 11/5/2018) Page 1-Application
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