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ELECTRICAL PERMIT APPLICATION <br /> CITY OF EVERETT PERMIT SERVICES <br /> EVERETT - 3200 CEDAR$111F.ET,EVERETT,WA Mtn <br /> WAS (P)425.257-8610 FAX 425-267-8857 I(E)everettpsfteverenvocgos I wwweverenwe.goefpernats <br /> HINGTON <br /> `.. .•:','44ag,..AP.34.t' ``.Nekta,,slge$4'4W4VA'',i, <br /> PROJECT ADDRESS: 517 Laurel Dr Everett WA 98201 BUILDING AREA: sq ft <br /> PROJECT TYPE: 0 NEW CONSTRUCTION 0 ADDITION 0 TENANT IMPRO'VMENT 0 REMODEL <br /> BUILDING USE: El SFR 0 TOWNHOUSE 0 DUPLEX 0 ADU 0 MULTI-FAMLY-#OF UNITS: 0 COMMERCIAL <br /> CONTRACT PRICE OF WORK:$ 6449.00 ASSOCIATED BUILDING PERMIT It applicable): <br /> DESCRIBE SCOPE OF WORK: <br /> retro t-stat and reconnect furnace <br /> THIS INSTALLATION INCLUDES THE FOLLOWING SCOPE:(SELECT ALL THAT APPLY) <br /> LINE VOLTAGE WORK? 0 NO 0 YES-Select Scope:0 Service 0 Feeder 0 Clrouits-#: 0 Complete Re-wire <br /> LOW VOLTAGE WORK? 0 NO DYES-#of Devices; <br /> SELECT SCOPE(REQUIRED):0 Data 0 intercom 13 Thermostat 0 Abdo 0 Secure Access 0 SectellY System <br /> 0 Are Alarm-Installations under this permit only include electrical wiring rough-in of the system.An additiored <br /> Fire Alan-Permit Is required for review of device location and Installation approval, <br /> Other(list <br /> :e:41F3N;< -,*,*':TT7Z4.10AZ.4.iatrrr:115ellitiaaT7,1•:77...: <br /> IS THIS PERMIT EDUCATION,INSTITUTKINAL.HEALTH ANWOR PERSONAL CARE FACILITIES: Ml NO NI YES See Below&Pg.2 <br /> DSy Checking this box,I am stating that I have read and understand all of WAC 29640400,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 /> E YOU AN OWNER PERFORMING WORK AS THE CONTRACTOR WITHOUT ELECTRICAL LICENSURE: Mi NO ES-See Below Pg.3 <br /> DPursuant to ROW 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,tam 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 iicensinntermicatlon requirement. <br /> Allati.4„Z,V4?;%1VINifaftlie *4.4* <br /> OWNER NAME:David IVIRSCarerleS TENANT BUSINESS NAME if Commercial <br /> •wNEN MAILING Atoms : smek.T. 517 Laurel Dr <br /> oily Everett - sum WA zr 98201 <br /> •* ER prioNEr425-259-6432 OWNER EMAIL: <br /> otrreAcroBNNEE; Nordstrom Heating &Air <br /> ONTRACTOR ADDRESS: grKEET4717 87th Ave NE <br /> ary Ma sville STATE VV8 98270 <br /> • p :360-388-9819 coNirgemog ese :OffiCO@TIOTOStTOITIlleatifl*„COM <br /> 1NTRACTOR LIC. REWIRED:nordsha8840 OF EVERE1T BUS LIG. -Rewrite) 042741 <br /> * D eyvN DC* -7, oft 0' a- ( ease <br /> ' CONTACT NAME: CONTACT PHONE:360-386-9819 <br /> Debbie or Cheryl CONTACT EMAIL:offiCeallOrtiStromheating.carn <br /> ACRE MEfff JherebyowWythaf(have reed and examated tha apolleation and know dm same to t hue end eared;Al'pm • sofiews and anfirances gewsring <br /> type of tvork wilt he completed whether specified herein or not. The granterg a a pematdoes not emote fo give authority 4o.vidate or calm/th e proWSIMS of any other state or <br /> too/low regulating muftis/ion orThe performance ofconshochen. Th a t I am authorised by•the owner of this property to pettarn the work for which application is made end I <br /> cow*with the State Contractors Law le.27RCWanci 296200 WAC. City of Everett OfScial Use Doty <br /> PERMIT#: <br /> OwneriAtithorized Agent Signature Date 7Revised ',Arne) Page i-Application <br />