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1 ELECTRICAL PIRMIT & FIRE ALARM P IT APPLICATION
<br /> 1 if!•414„,P,,-'—.....A
<br /> CITY OF EVERETT PERMIT SER imlll.
<br /> 04
<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: ///2,7 El/elf€ . felAy WA/k50 *fro /o, ,, toil are",
<br /> PROJECT TYPE: 0 NEW CONSTRUCTION 0 ADDITION 0 TENANT IMPR MENT 0 REMODEL
<br /> BUILDING USE: 0 SFR 0 TOWNHOUSE 0 DUPLEX 0 ADU 0 MULTI-FAMILY-#OF UNITS: IQ COMMERCIAL
<br /> BUILDING AREA: sq ft
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<br /> CONTRACT PRICE OF WORK:$ iO0 . 00 ASSOCIATED BUILDING PERMIT#(if applicable):
<br /> IS THIS LOW VOLTAGE WORK? 0 NO 13 3<--#OF DEVICES: t't'
<br /> IS THIS A FIRE ALARM PERMIT? 0 NO 0 YES-Plans required for
<br /> review(Both E
<br /> lectrical and Fire Department inspections are required)d)
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<br /> DESCRIPTION OF WORK: A Cviscf C f$1iw.i#Y A-7,0 S6 t7 a.R;p
<br /> IS THIS PERMIT EDUCATION,INSTITUTIONAL,HEALTH AND/OR PERSONAL CARE FACILITIES: 0 NO 0 YES--See Below&Pg.2
<br /> ❑ 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:far() OYES-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 without
<br /> the proper electrical licensing and certification,or exemption.By checking this box,I am stating that I have completed and signed the
<br /> See Page 3 AFFIDAVIT on page 3 of this application to receive an exemption from this licensing/certification requirement.
<br /> t ONTACT INFORMATION
<br /> OWNER NAME: A 6'. C. 14 . TENANT BUSINESS NAME(If Commercial):
<br /> OWNER MAILINGG ADDRESS: STREET ///2 7 Y / cr s.... W4-y
<br /> IL
<br /> ,(r w'.(4_ CITY /STATE ��- ZIP 9,24 y
<br /> OWNER PHONE: OWNER EMAIL:
<br /> CONTRACTOR NAME: 7/tj fr 4o /^(L .
<br /> CONTRACTOR ADDRESS: STREET 93L Zipr zwir y DI' g1_ Zy•
<br /> � (^/i CITY STATE Wo— ZIP Afar
<br /> CONTRACTOR PHONE: 4,24/ f'/ CONTRACTOR EMAIL: gelf. fe//,rf 0 e/GLet-a , ev oi .
<br /> CONTRACTOR LIC.#(REQUIRED):Di&ip•bof /7 9J, rr CITY OF EVERETT BUSINESS LIC.#(REQUIRED): 4-. 35K
<br /> PRIMARY CONTACT: ❑OWNER CONTRACTOR 0 OTHER(Please Specify) � •i-S.P/&vj v/Ehpd.d
<br /> CONTACT NAME: CONTACT PHONE: 7 zr SO e/si - /
<br /> T44 .t//ers' CONTACT EMAIL: `7 $, //mss 4,0 gerszes, , Ge-rr-,(
<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
<br /> governing this 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
<br /> provisions of any other state or local law regulating construction or the performance of construction. That I am authorized by the owner of this property to perform the
<br /> work for which application is made and I comply with the State Contractors Law 18.27 RCW and 296.200 WAC.
<br /> City of Everett Official Use Only
<br /> PERMIT#
<br /> Owne uthorized Agent Signature Date (Revised 11/5/2018) Page 1-Application
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