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<br /> _ ELECTRICAL PERMIT APPLILATION
<br /> CITY OF EVERETT PERMIT SERVICES
<br /> 3200 CEDAR STREET,EVERETT,WA 98201
<br /> (P)425-257-8810 I FAX 425-257-8857 1(E)everetteps@everettwa.gov I www.everettwa.gov/Permits
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<br /> PROJECT ADDRESS: B JAxdusT Sr STS A
<br /> BUILDING AREA: sq ft
<br /> PROJECT TYPE: 0 NEW CONSTRUCTION 0 ADDI ION 0 TENANT IMPROVMENT '_REMODEL
<br /> BUILDING USE: 0 SFR 0 TOWNHOUSE
<br /> 0 DUPLEX 0 ADU 0 MULTI-FAMILY-#OF UNITS: ': COMMERCIAL
<br /> MiNffinfat 4 'Ig ONI OR TCESIRy TE6tgVeg
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<br /> CONTRACT PRICE OF WORK:$ 3 00.c9--- (ASSOCIATED BUILDING PERMIT#(if applicable):
<br /> DESCRIBE SCOPE OF WORK: P.p: 1 P et j i 1�/t-R X�U r{,5 A'h d t g(I�"cP
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<br /> THIS INSTALLATION INCLUDES THE FOLLOWING SCOPE: (SELECT ALL THAT APPLY)
<br /> LINE VOLTAGE WORK? 0 NO ®YES-Select Scope: 0 Service 0 Feeder Circuits-#: I 0 Complete Re-wire
<br /> LOW VOLTAGE WORK? 0 NO 0 YES-#of Devices:
<br /> SELECT SCOPE(REQUIRED):
<br /> 0 Data 0 Intercom 0 Thermostat 0 Audio '0 Secure Access 0 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): /a y�y� A _
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<br /> IS THIS PERMIT EDUCATION,INSTITUTIONAL,HEALTH AND/OR PERSONAL CARE FACILITIES: �NO il YES--See Below&Pg.2
<br /> 74 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 YOUAN OWNER PERFORMING WORK AS THE CONTRACTOR WITHOUT ELECTRICAL LICENSURE: ONO EYES-See Below&Pg.3
<br /> El 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.
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<br /> OWNER NAME: M4 Evain—TA L.T ENANT BUSINESS NAME(If Commercial):
<br /> OWNER MAILING ADDRESS: STREET /1 i.2 Zhd 5T7 ST;
<br /> CITY �v.G/'G 71
<br /> STATE MIA' ZIP 1$'2fJ
<br /> OWNER EMAIL:
<br /> OWNER PHONE: S `I • A . ,». r �. „
<br /> -.. x ..-: �.�.��a_, _ .tee �:.
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<br /> CONTRACTOR NAME: 64 ttel----
<br /> CONTRACTOR ADDRESS: STREET
<br /> CITY STATE ZIP
<br /> CONTRACTOR PHONE: (CONTRACTOR EMAIL:
<br /> CONTRACTOR LIC.#(REQUIRED): CITY OF EVERETT BUSINESS LIC.#(REQUIRED): µ
<br /> PRIMARY CONTACT: Ig OWNER 0 CONTRACTOR 0 OTHER(Please Specify) q(
<br /> CONTACT NAME: CONTACT PHONE: (2. i ?j`1 7 .c,„2.0t
<br /> DIE- CQKoloic 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 governing this
<br /> local law regulating construction or the performancspecified e of constructein or not. ion.granting
<br /> lam authorized by the owner of this property to perform the work for theprovisions
<br /> yapplication is made anny other d I or
<br /> City of Everett Official Use Only
<br /> comply with the State Contractors Law 18.27 RCW and 296.200 WAC. PERMIT#:
<br /> /41 // / x.......04...--\.€7_ E 016+ q
<br /> Date (Revised 1/11/2019) Page1-pplication
<br /> Owner/Authorize.tent Signature 3
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