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Apr 20 19 12:19a Bob Jack 15096746777 p.1 <br /> ELECTRICAL PES; F APPLICATION <br /> CITY OF EVERETT PERMIT SERVICES <br /> '..P47.:4 3200 CEDAR STREET,EVERETT,WA 98201 <br /> (P)425-257-8810 I FAX 425-257-8857 I(E)evereltepsOevereth52.gov I wMr.everettxa.gov/permits <br /> PROJECT ADDRESS: % //...2 - �, - BUILDING AREA:_ /0V sq ft <br /> PROJECT TYPE: 0 NEW CONSTRUCTION 0 ADDITIONENANT IMPROVMENT O REMODEL , <br /> BUILDING USE: 0 SFR El TOWNHOUSE ® DUPLEX 0 ADU ®MULTI-FAMILY-#OF UNITS: COMMERCIAL <br /> EL pCTRYCAIL.APPLICATION INFORIvMATIoN & .ESCRIPT60N OF-1i14ORRi <br /> CONTRACT PRICE OF WORK:$ ,'/.fl 9 ASSOCIATED BUILDING PERMIT#(if applicable):�applicable):` <br /> DESCRIBE SCOPE OF WORK: 1,lj 7 14// Ne ) �' -S Y!f�"' - D <br /> _ 5 r <br /> I <br /> THIS INSTALLATION INCLUDES THE FOLLOWING SCOPE:(SELECT ALL THAT APPLY) <br /> LINE VOLTAGE WORK? 0 NO 0 YES-Select Scope:0 Service 0 Feeder 0 Circuits.-#: 0 Complete Re-wire <br /> LOW VOLTAGE WORK? O NO- ES-#of Devices: / <br /> SELECT SCOPE(REQUIRED): 9Vita 0 Intercom O Thermostat 0 Audio 'O Secure Access 0 Security System <br /> 0 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 /> . c.orYECCMPL.''IA[NC - -� - <br /> IS THIS PERMIT EDUCATION, INSTITUTIONAL,HEALTH AND/OR PERSONAL CARE FACILITIES: riii <br /> ® co O 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,-sePected 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: LO OYES-See Below 8.Pg.3 <br /> ® Pursuant to RCW 19.28.261, property owners and leaseholders cannot perform electrical work on bu�din`gs for rent,sale,or lease <br /> I 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 /> z4 .rtP4, CONTACT INFOR(4MAT1ON T,, z' <br /> OWNER NAME: 11-JL1�) /-ervirD TENANT BUSINESS NAME(If Commercial): /—e/S4(1y7 <br /> OWNER MAILING ADDRESS: STREET i <br /> !'57� /'ice-11iS 7: S. <br /> 'A <br /> crn ----(..)-e-(' 44--� STATE {fir Y` f•, nP }� <br /> 'OWNER PHONE: OWNER EMAIL: <br /> CONTRACTOR NAME: 111 *,jC Uj'� % <br /> CONTRACTOR ADDRESS: STREET S ..- /- iejeOek <br /> CITY /`a(mss- yr./1'N <br /> r1 STATE c)f ZIP d i . . <br /> - <br /> CONTRACTOR PHONE: 7.3,572 CONTRACTOR EMAIL: -t,c-k, (- 116► _. Cr?`Ere ' <br /> CONTRACTOR LIC.f/IREQUIRED) CITY OF EVERETT BUSINESS LIG.#,REQUIRED): L`t <br /> PRIMARY CONTACT: 1:1 OWNER iSONTRACTOR 0 OTHER(Please Specify) <br /> CONTACT NAME: ////// CONTACT PHONE: .�, J9 <br /> 41101.010 d iiP. CONTACT EMAIL: A r <br /> AGREEMEi% I hereby certifyth- have read and examined this application and know the c, :to be true and correct. AU provisions of laws and ordinances governing this <br /> typo of war•will be completed whet -r specified horein 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 re..utating construction or t -perfo ance of construction- That I am authorized by the cwner o!Oils property to perform true tivork for which application is made and f <br /> comply will the State Contractors La PERMjT#f 1%RCWeed 290.200 WAD. CI of Everett Official Use Only <br /> - d , E I0 �� - Ind <br /> Owner/Ar hortzod ••en igna re Dale (Revised 1/11/2010) Page 1-Application <br />