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111 m
<br /> `! ELECTRICAL PERMIT APPLICATION
<br /> CITY OF EVERETT PERMIT SERVICES
<br /> EVERETT 3200 CEDAR STREET,EVERETT,WA 98201
<br /> WASHINGTON (P)425-257-8810 I FAX 425-25'.7-''!)
<br /> 7,-8857. 1(E)everetteps@everettwa.gov I.awww.everettwa.gov/permits '3,
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<br /> PROJECT ADDRESS: eA - s SUt�i_ 4 BUILDING AREA: sq ft
<br /> PROJECT TYPE: ❑ NEW CONSTRUCTION L_1 ADDITION E TENANT IMPROVMENT ❑ REMODEL
<br /> BUILDING USE: El SFR ❑TOWNHOUSE ❑ DUPLEX ❑ADU ❑MULTI-FAMILY-#OF UNITS: ®COMMERCIAL
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<br /> CONTRACT PRICE OF WORK:$ Z 2b .� (ASSOCIATED BUILDING PERMIT#(if applicable):
<br /> DESCRIBE SCOPE OF WORK: vw(, --D\l'C 19 i 12-O 4 a,E-- 2-SM NlP CAW,T S
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<br /> THIS INSTALLATION INCLUDES THE FOLLOWING SCOPE: (SELECT ALL THAT APPLY)
<br /> LINE VOLTAGE WORK? ❑ NO ❑YES-Select Scope:❑Service ❑ Feeder -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 /> IS THIS PERMIT EDUCATION,INSTITUTIONAL,HEALTH AND/OR PERSONAL CARE FACILITIES: MINOa YES--See Below&Pg.2
<br /> nBy 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 /> �I
<br /> IPursuant 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: TENANT BUSINESS NAME(If Commercial):iac Lr '1'\4r`-(- C� -
<br /> OWNER MAILING ADDRESS: STREET �j6Dq 5, 1,�)0.O5,t - 2T)1 g3 LO".5% ,rte G3ry"
<br /> CITY 1,Akk O STATE t pt O aA 00 ZIP wO23c
<br /> OWNER PHONE:112c' 3` 1'02 b OWNER EMAIL: J p c.nne .@ 9Mvmil f 6_(pththGr` Or`I.r.e C uf'
<br /> CONTRACTOR NAME: rc,117,1 X"-t( (_ It, P (`
<br /> CONTRACTOR ADDRESS: STREET )2 5- II'� ` L S L
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<br /> CrrY �_�lZ,/LSC; 1 STATE vjA ZIP q26D v
<br /> CONTRACTOR PHONE: 92S, 9'70'be ,CONTRACTOR EMAIL: �a,,e___@ 03‘_-lec-Pt.9C- C °n-•
<br /> CONTRACTOR UC.#(REQUIRED) 1),3kth-gEl D y CITY OF EVERETT BUSINESS LIC.#(REQUIRED): 4--(1.,113:4-
<br /> PRIMARY CONTACT: DOWNER OCONTRACTOR ❑OTHER(Please Specify)
<br /> CONTACT NAME: CONTACT PHONE: tA ZS` Q'?0 --600°`
<br /> Ii4N3 M 1424 9-,r Z. CONTACT EMAIL: bate @- p$,kt.-Lvi tL' La/-i
<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 /> 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 I
<br /> comply with the S ate Contractors Law 18.27 RCW and 296.200 WAC. City of Everett Official Use Only
<br /> PERMIT#:
<br /> 4
<br /> 11, - 24;11 E 10(o—ne61
<br /> Ow _ orized Agent Signature Date (Revised 1/11/2019) Page 1-Application
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