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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 1(E)everetteps@everettwa.gov I www.everettwa.gov/permits •
<br /> ! > PROJECT'SIi"E. NFO;RMAION <.;
<br /> PROJECT ADDRESS:AV).()C do v-Apt, I) -1- P)l BUILDING AREA: 12.a,j sq ft
<br /> PROJECT TYPE: El NEW CONSTRUCTION CI ADDITION 0 TENANT IMPROVMENT ,OREMODEL
<br /> BUILDING USE: ❑SFR ❑TOWNHOUSE ❑DUPLEX ❑ADU ,MULTI-FAMILY-#OF UNITS: El COMMERCIAL
<br /> ELECTRICAL{APPLICATION:,INFO;RMATI.ON::::&t©ESCRIPTIO:N iOF;WORK• , ,
<br /> ��.� ,,tip;,: �
<br /> CONTRACT PRICE OF WORK:$ 3 O33,--rik ASSOCIATED BUILDING PERMIT#(if applicable):
<br /> D•
<br /> ESCRIBE SCOPE OF WORK: ,,t r Cm11(llJ 3 (" y-,V9c `r S--flu,
<br /> - hQa- ys . - 1 -lam? ,Gi-�� home-
<br /> THIS INSTALLATION INCLUDES THE FOLLOWING SCOPE: (SELECT ALL THAT APP /
<br /> . LINE VOLTAGE WORK? PrICO OYES-Select Scope: El Service ❑ Feeder �� Circuits-#: . El Complete Re-wire •
<br /> LOW VOLTAGE WORK? ONO ❑YES-#of Devices:
<br /> SELECT SCOPE(REQUIRED): CI Data El Intercom ❑Thermostat El Audio El Secure Ac s 0 Security System
<br /> El Fire Alarm-Installations under this permit only include ele N rical wirin ugh-in of the system.An additional
<br /> Fire Alarm Permit is required for review of device location and installation approval.
<br /> El Other(List All):
<br /> k , :sCO.DE iCOMPUANCE
<br /> IS THIS PERMIT EDUCATION,INSTITUTIONAL HEALTH AND/OR PERSONAL CARE FACILITIES: ENO D YES—See Below&Pg.2
<br /> 17 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:LINO 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 /> 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: V - l SVvirli p()S TENANT BUSINESS NAME(If Commercial):
<br /> OWNER MAILING ADDRESS: !l STREET qls jZU(lr el✓Ave_ >J
<br /> CnY E ve r-Q t- STATE ZIP Cig)�j
<br /> OWNER PHONE:Mg— t�j�..L4JJq� OWNER EMAIL: ^{S Whj 9(c'y bin,
<br /> CONTRACTOR NAME: 6 5 t l
<br /> CONTRACTOR ADDRESS: STREET 2Lt01,•-eit
<br /> CITY � y STATE A ZIP Ctdcr
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<br /> CONTRACTOR PHONE:`4 aC. '}(0-14.19,„s1 'CONTRACTOR EMAIL: ,C)cum (,G,c
<br /> CONTRACTOR LIC.#(REQUIRED): C']S1-1C, F(CL CITY OF EVERETT BUSINESS LIC.#(R!' UIRED): (0(0O,54'
<br /> PRIMARY CONTACT: DOWNER L"JCONTRACTOR ❑OTHER(Please Specify)
<br /> CONTACT/ NAME: { CONTACT PHONE: 4--io ��gW 1.(��c”
<br /> Sc k 1�ark a CONTACT EMAiL: J'ittf(-fC\, 1 �Y1�'J4 1/1 ► ,
<br /> AGREEMENT:1 hereby certify that!have read and examined this application and know the same to b� correct. Al!provisio f laws and ordinances governing this
<br /> 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 provisions of any other state or
<br /> local law regulating construction or the performance of construction. That lam authorized by the owner of this property to perform the work for which application is made and!
<br /> comply with the State Contractors Law 18.27 RCW and 296.200 WAC. City of Everett Official Use Only
<br /> PERMIT#:
<br /> CtCg/0 ; 4414 ) I°1 E
<br /> wnerIAuzed Agent Signature Date (Revised 1/11/2019) Page 1-Application
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