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<br /> ELECTRICAL PERMIT APPLICATION
<br /> CITY OF EVERETT PERMIT SERVICES
<br /> EVERETT 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.gov/ en1its `,
<br /> ' PROJECT SITE'INFORMATION ,'
<br /> Z� BUILDING A �'A � s ft
<br /> PROJECT ADDRESS: k-�,c /�` t 1 q
<br /> PROJECT TYPE: ❑ NEW CONSTRUCTION ❑ADDITION ❑TENANT IMPROVMENT V) '' MODEL
<br /> BUILDING USE: LS-SFR ❑TOWNHOUSE ❑ DUPLEX ❑ADU ❑ MULTI-FAMILY-I'',OF UNITSV E COMMERCIAL
<br /> :ELECTRICAL APPLICATION°INFORMATION Si,'DESCRIP. ®,F'WORR .
<br /> CONTRACT PRICE OF WORK:$ ..5-0 0 o.00 ASSOCIATED BUILDING PERMIT#(if applicable):" j
<br /> DESCRIBE SCOPE OF WORK: tC-i, ,,, 12-rCo cct� /tjci `,,t4 mit- l Pk .(' uppri
<br /> /'Oi i Q '�
<br /> THIS INSTALLATION INCLUDES THE FOLLOWING SCOPE: (SELECT ALL THAT APPLY)
<br /> LINE VOLTAGE WORK? ❑ NO 11 YES-Select Scope:N Service ❑ Feeder K Circuits-#: `] ❑ Complete Re-wire
<br /> LOW VOLTAGE WORK? ® NO ❑YES-#of Devices:
<br /> SELECT SCOPE(REQUIRED): El 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: r0-NO n 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: ONO 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.
<br /> CONTACT INFORMATION
<br /> OWNER NAME oy f, 1l Ts.,,cyti(,„ TENANT BUSINESS NAME(If Commercial):
<br /> �'�
<br /> OWNER MAILING ADDRESS: STREET i417,--/, rw, kc /
<br /> u .La___ (}
<br /> CITY STATE
<br /> "k ZIP [ -6 20,13
<br /> OWNER PHONE: OWNER EMAIL:
<br /> CONTRACTOR �r. .,... ._�Y ,. ...� ,. -___. . „„ a Q. , ,. _ . .... , ,,.�_ _
<br /> NAME: 4GK,,t, \4Q tISCI.,
<br /> CONTRACTOR ADDRESS: STREET 3%t7_, 4-7ir"‘ "r• SE--
<br /> CITY , �'�() C ► STATE �}`'-'1 ZIP
<br /> CONTRACTOR PHONE: 47 94,s (702,7„CONTRACTOR EMAIL: �r)n � �c,4y't„
<br /> � � de�—r+uc#(•� e(`c.VeA It 'Ll • iC .^-,
<br /> CONTRACTOR LIC.#(REQUIRED) IYc Mt P CITY OF EVERETT BUSINESS LIC.#(REQUIRED):
<br /> PRIMARY CONTACT: DOWNER [CONTRACTOR ❑OTHER(Please Specify)
<br /> CONTACT NAME:: CONTACT PHONE: 4 i --y 3 c6 2,-L,N t`�� (A - \ CONTACT EMAIL: GL,.,-oI Ll tiLp pv.i.L 0, ly,,:i I.cc iii
<br /> AGREEMENT:I hereby certify that I have read and examined this application and know the same to A 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 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 Law 18.27 RCW and 296.200 WAC. City of Everett Official Use Only
<br /> PERMIT#:
<br /> � � 6/(672c2/7 E ��oC� - OCA O
<br /> •wne .•re'orizedAgent Signature D e (Revised 1/11/2019) Page 1-Application
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