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ELECTRICAL PERMIT APPLICATION <br /> CITY OF EVERETT PERMIT SERVICES <br /> 3200 CEDAR STREET,EVERETT,WA 98201 <br /> (P)425-257-8810 I FAX 425-257-8857 I(E)everetteps@everellwa.gov 1 www,everettwa,govlpermits <br /> Ogrr <br /> PROJECT SITE INFORMATION <br /> PROJECT ADDRESS: 1430 w (S lino 1-2-eA + ?-i 'C vr/C1(BUILDING AREA: sq ft <br /> PROJECT TYPE: ❑NEW CONSTRUCTION 111ADDITION IN,ENANT IMPROVMENT ❑ REMODEL <br /> BUILDING USE: ❑SFR ❑TOWNHOUSE ❑DUPLEX ❑ADU MULTI-FAMILY-#OF UNITS:lAfl5vir' ❑COMMERCIAL <br /> ELECTRICAL APPLICATION INFORMATION R DESCRIPTION OF WORK <br /> CONTRACT PRICE OF WORK:$ "l 00 ASSOCIATED BUILDING PERMIT#(if applicable): <br /> DESCRIBE SCOPE OF WORK: C3)O'tt C/iy-m (i ',$ -foV I- vi -, -t Q..t fi ,S'(/IIi-rci(/( <br /> THIS INSTALLATION INCLUDES THE FOL WING SCOPE:(SELECT ALL THAT APPLY) <br /> LINE VOLTAGE WORK? ❑NOt'ES-Select Scope:❑Service ❑Feeder 7 Circuits-#: ❑Complete Re-wire <br /> LOW VOLTAGE WORK? ❑NO ❑YES-#of Devices: <br /> SELECT SCOPE(REQUIRED): ❑Data ❑Intercom ❑Thermostat ❑Audio El Secure Access ❑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 /> ,i CODE COMPLIANCE <br /> IS THIS PERMIT EDUCATION,INSTITUTIONAL,HEALTH AND/OR PERSONAL CARE FACILITIES: n NO'---U 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:ENO 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 /> CONTACT INFORMATION ,:, ',V47.1.7: ',. . ,. <br /> OWNER NAME: p Y't0n 'O(ne t" - TENANT BUSINESS NAME(If Commercial): <br /> OWNER MAILING ADDRESS: STREET G{3�0w- �' tfl0 Q4 2.-2_1 �y} <br /> COY (' t-��I.ISTATE ZIP nq-z o I <br /> OWNER PHONE: Vi( A �p ��DOWNER EMAIL: V\. .9\-- <br /> CONTRACTOR <br /> 2' - <br /> CONTRACTOR NAME:[ V\ ' Q- <br /> CONTRACTOR ADDRESS: STREET 10/2X) W1-VI/�'OY CS ALP- <br /> /V�1 (� <br /> CITY Y" 8�''�/' ‘e-AA"`7 STATE-,-1-907v-v, <br /> -ATE, zip <br /> `n�? <br /> CONTRACTOR PHONE:•- / 7 196 7 L,0�f CONTRACTOR EMAIL: LV eiTr/WV}I 1 907v >, Ott 1 ' „W� Y t <br /> CONTRACTOR LIC.#(REQUIRED): N H-Dvt- 6A 0-ZQ.tOf CITY OF EVERETT BUSINESS LIL!#(REQUIRED): 044-I ,g o <br /> PRIMARY CONTACT: DOWNER feCONTRACTOR ❑OTHER(Please Specify) <br /> CONTACT NAME: CONTACT PHONE: 2-k-1-2_ 'i(4- 1 <br /> v CONTACT EMAIL: (Nij r`�lam" v'1 Y 101(.1 . VQ/VIA <br /> AGREEMENT:I hereby certify that I have read and examined this application and know the same o be true and correct. A provisions of laws and ordinall.,.es governing this <br /> type of work will be completed whether specified h.- .in or 01, The granting of a permit does not presume to give authorily to violate or cancel the provisii-s of any other slate or <br /> local lav =gulatin.construction or the perfo •.nce of const•coon, That I am authorized by the owner of this property to perform the work for which app'ication is made and I <br /> co..y with the ale C. tractors Law 18• RCW. •296 00 WAC. City of Everett Official Use Only <br /> PERMIT#: <br /> ,/ Aft.imme -2s /7 E 10[03- 1 ( ! <br /> Own: /Authorize."-gent gnat - / Date (Revised 1111/2019) " <br /> F=r ge 1-Application <br /> Scanned with CamScanner <br />