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• <br /> ELECTRICAL PERMIT APPLICATION <br /> CITY OF EVERETT PERMIT SERVICES <br /> '-Cl 3200 CEDAR STREET,EVERE r,WA 88201 <br /> (P)425-257-8810 I FAX 425-257.8857 I(E)everettosgeverettwa.gov www.everettwa goy/permits <br /> PROINOVil141111111RMA41:014 <br /> PROJECT ADDRESS: 7tL3 St se cAI BUILDING AREA: sq ft <br /> PROJECT TYPE: El NEW CONSTRUCTION ADDITION El TENANT IMPROVMENT 0 REMODEL <br /> BUILDING USE: El SFR El TOWNHOUSE El DUPLEX El ADU 0 MULTI-FAMILY #OF UNITS: fk1 COMMERCIAL <br /> , _ VOIMICR,TIWORANOSOC <br /> CONTRACT PRICE OF WORK:$ I LtJb, C 'ASSOCIATED BUILDING PERMIT*(if applicable): <br /> DESCRIBE SCOPE OF WORK: a k tfe.r-t c r c„it( -czy e xi ft <br /> I <br /> THIS INSTALLATION INCLUDES THE FOLL• NG SCOPE:(SELECT ALL THAT APPLY) <br /> LINE VOLTAGE WORK? El NO I YES-Select Scope:CI Service El Feeder E]Circuits-#: El Complete Re-wire <br /> LOW VOLTAGE WORK? El NO El YES-#of Devices: <br /> SELECT SCOPE(REQUIRED): El Data 0 Intercom El Thermostat El Audio 0 Secure Access El Security System <br /> El 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 /> El Other(Lila All): <br /> IS THIS PERMIT EDUCATION,INSTITUTIONAL HEALTH AND/OR PERSONAL CARE FACIUTIES: 21 NO U YES—See Below&Pg.2 <br /> — By checking this box,I am stating that I have read and understand all of WAC 29646B-90D,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:tRNO EYES-See Below&Pg.3 <br /> — Pursuant to RCW 19.28261,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. <br /> OWNER NAME: SO ik rt5 fl P r-012e e TENANT BUSINESS NAME(If Corninercial):(Letzy /34 y ie3 re <br /> OWNER MAILING ADDRESS: ennsEr f 0 D)C 13 685 <br /> °ay CV!! V' fk STATE IAA ZE4 S.:2'0 <br /> OWNER PHONE: OWNER EMAIL: <br /> gg ,j7 , • <br /> CONTRACTOR NANIE: 130sci4 Cue-crate INC. <br /> CONTRACTOR ADDRESS: srasEr Po Box 10(65 <br /> CITY LA-1'x si-gveNs <br /> STATE t/ti A S'1.58 <br /> CONTRACTOR PHONE: 41/6 q1 te 6 CONTRACTOR EMAIL: be e let.t EtCfri Oull 00 k CO-Pvt. <br /> CONTRACTOR LIC.#(,,REOUIRED): gOSCI4gt qt.%30r Ica),OF EVERETT BUSINESS LIC.#(REQUIRED: 4f.p '1 If, „ <br /> PRIMARY CONTACT: DOWNER [ CONTRACTOR DOTHER(Please Specify) <br /> CONTACT NAME: CONTACT PHONE: 42,5 3 et-7 g 7te s—o,i L/2.5 q 144 <br /> Tog- f3osci-t CONTACT EMAIL: 1:70cC k. 'cb' ivtc e 0 Latoo IL,c.cyy, <br /> AGREEMENT:!hereby certify that!have read and examined thle 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 audio*to violate or cancel the Provisions of any other state or <br /> local taw regulating construction or the performance of construction. That!am authorized by the owner of this property to perform the wont for which application is made and I <br /> comply with the State Contractors Law 18.27 RCW and 298.200 WAC City of Everett Official Use Only <br /> PERMIT#: <br /> E <br /> 0 r/ <br /> wrt,,, ejLt Oc\, <br /> Authorized Agent Signature Date (Revised I 11/2019) Page 1-Application <br />