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ELECTRICAL PERMIT APPLICATION <br /> EVERETT CITY OF EVERETT PERMIT SERVICES <br /> 3200 CEDAR STREET,EVERETT,WA 98201 <br /> WASHINGTON (P)425-257-8810 I FAX 425-257-8857 I(E)everetteps@everettwa.gov I www.everettwa.govlpermits <br /> PROJECT SITE INFORMATION <br /> PROJECT ADDRESS: 1 aO Lk) BUILDING AREA: sq ft <br /> PROJECT TYPE: ❑ NEW CON :dCTION El A*EDITION .I TENANT IMPROVMENT El REMODEL <br /> BUILDING USE: ❑SFR I! TOWI H USE DUPLEX ❑ADU El MULTI-FAMILY-#OF UNITS: [ COMMERCIAL <br /> ELEC ' 'ICALiAPPLIC TION INFORMATION 8 DESCRIPTION OF WORK <br /> CONTRACT PRICE OF WOR :$ 9 . ASSOCIATED BUILDING PERMIT#(if applicable): ./Q74c 1 . <br /> t� (. <br /> DESCRIBE SCOPE OF W��RK: Prj J j 20 <br /> de C 3) 14 Ci&..au5 J�" <br /> ty C.oT tl•tr <br /> THIS INSTALLATION INCLUDES THE FOLLOWING SCOPE:(SELECT ALL THAT APPLY) <br /> LINE VOLTAGE WORK? ❑ NO ®YES-Select Scope: <br /> ❑Service ❑ Feeder 21.Circuits-f/: Complete Re-wire <br /> LOW VOLTAGE WORK? ®.NO ❑YES-#of Devices: <br /> SELECT SCOPE(REQUIRED): ❑ Data ❑Intercom ❑Thermostat ❑Audio ❑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 /> CODE COMPLIANCE <br /> IS THIS PERMIT EDUCATION,INSTITUTIONAL,HEALTH AND/OR PERSONAL CARE FACILITIES: ❑NO ❑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: ENO EYES-See Below&Pg.3 <br /> Pursuant to RCW 19.28.261,property owners and leaseholders cannot perform electrical work on buildings f• - , -I•, • -ase <br /> LTwithout the proper electrical licensing and certification,or exemption.By checking this box, I am statin• at I have completed . d <br /> See Page 3 signed the AFFIDAVIT on page 3 of this application to receive an exemption from this licensi : certification requirement. <br /> •,-. CONTACT INFORMATION: <br /> OWNER NAME: TENANT BUSINESS NAME(If Comme ial): <br /> OWNER MAILING ADDRESS: STREET <br /> CITY STATE _ ZIP <br /> OWNER PHONE: I ' /� OWNER EMAIL: <br /> CONTRACTOR NAME: 5€ RO y A H E L ( 7 t �y <br /> CONTRACTOR ADDRESS: STREET 15126 <br /> cIT( VV10N STATE UJe ZIP ST)52— <br /> CONTRACTOR PHONE: y 25--r61 L- 1.c000 CONTRACTOR EMAIL: ANN;8.by(4. kt�i`xc�t `Ir}41�•COWL <br /> CONTRACTOR LIC.#(REQUIRED):`je .1JlQt%LCI 1 7'5j CITY OF EVERETT BUSINESS LIC.#(REQUIRED): (,Lk 5 <br /> PRIMARY CONTACT: Cl OWNER ,CONTRACTOR ['OTHER(Please Specify) <br /> CONTACT NAME: CONTACT PHONE: L(7 -'1c -9.1 L,C(` <br /> k\)-ia€x CONTACT EMAIL: orverr, jtvyclut Ct. ctLtoyA f-I .LAM <br /> AGREEMENT:I hereby certify that I have read and examined this application and know the same to be true and correct. All provisl s of lbws end 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 I am authorized by the owner of this property to perform the work for which application Is made and I <br /> comply with the State Contractors ;.27 RCW and 296.200 WAC. City of Everett Official Use Only <br /> PERMIT#: <br /> '-_. Isq 1CkE O - 035 <br /> Owner/Authorized Agent aip, e Date (Revised 1/11/2019) Page 1-Application <br />