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08/19/2019 09 : 08 #4371 P. 001/001
<br /> `I ELECTRICAL PERMIT APPLIGA1TION
<br /> CITY OF EVERETT PERMIT SERVICES
<br /> EVERETT 3200 CEDAR STREET,EVERETT,WA 98201
<br /> HkNaTON (P)425-257-8810 I FAX 425-257-8857 I(E)ever eps(�e erettwa.go I •avers +s
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<br /> PROJECT . . 9930
<br /> PROJECT ■ NEW CONSTRUCTION ■ ADDITION Li TENANT IMPROVMENT ••
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<br /> BUILI3ING USE: ■ SFR El TOWNHOUSE ■ t�1COMMERCIAL
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<br /> 1200
<br /> CONTRACT PRICE OF WORK:$ ASSOCIATED BUILDING PERMIT#(if applicable):
<br /> DESCRIBE • - OF WORK:
<br /> 20 AMP DEDICATED CIRCUIT FOR COPIER MOVED TO TEMPORARY LOCATION, NO LOAD INCREASE
<br /> THIS INSTALLATION INCLUDES THE FOLLOWING SCOPE: (SELECT ALL THAT APPLY)
<br /> LINE VOLTAGE WORK? 5 No IE YES-Select Sc-ope: D Service El Feeder NE Circuits4:1 E Complete Re-wire
<br /> LOW VOLTAGE WORK? ■ NO r of Devices:
<br /> SELECT SCOPE . - . LI Data ■ ■ Thermostat 17 Audio El Sec.ure Access ■
<br /> Security System
<br /> 0 Fire Alarrn-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 /> D Other(List All):
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<br /> IS THIS PERMIT EDUCATION,INSTITUTIONAL,HEALTH AND/OR PERSONAL CARE FACILITIES: 0 NO 1.1 YES--See Below&Pg.2
<br /> LBy checking this box, I am stating that I have read and understand all of WAC 296.46E-900,selected the specific reason on page 2
<br /> of this application(see next page),AND Plan Review is NOT required because l 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: d NO 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_
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<br /> OWNER NAME THERAPEUTIC HEALTH SERVICES TENANT BUSINESS NAME If Commercial :
<br /> OWNER MAILING ADDRESS: „,, Er 9930 EVERGREEN WAY Z-150
<br /> cin, EVERETT sTATh WA ZiP 98204
<br /> OWNER PHONE:425.61.38321 OWNER EMAIL:
<br /> CONTRACTOR NAME: EYLANDER SALES a SERVICE
<br /> CONTRACTOR ADDRESS: STR*Er3601 EVERETT AVE
<br /> cif- EVERETT sTATR WA zip 98201
<br /> CONTRACTOR PHONE:425•259.2161 CONTRACTOR EMAIL:Jceylander@yahoo.com
<br /> CONTRACTOR LIC.#(REQUIRED):EYLANSS142LP CITY OF EVERETT BUSINESS LIC.#{REQUIRED)_016363
<br /> PRIMARY CONTACT: DOWNER QCONTRACTOR OTHER(Please Specify)_
<br /> CONTACT NAME: CONTACT PHONE:425.231.2275
<br /> corny 1 St CONTACT EMAIL:jceylander@yahoo.com
<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 regula in constrict/on or the performance of construction. That I em authonZed by the owner of this property to perform the work for which application is made and I
<br /> comply with ':State Contractors Law 18.27 RCW and 296.200 WAC, City of Everett Official use Only
<br /> PERMIT#:
<br /> E \ oDi - \ of
<br /> O "er/Au orized Agent Signature Date / (Revised 1/11/2019) Page 1-ApplrcatIon
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