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111 477- ELECTRICAL PERMIT APPLICX I ION <br /> CITY OF EVERETT PERMIT SERVICES <br /> 3200 CEDAR STREET,EVERETT,WA 98201 <br /> (P)425-257-8810 I FAX 425-257-8857 1(E)everetteps@everettwa.gov 1 www.everettwa.gov/permits <br /> PROJECT SITE INFORMATION, <br /> PROJECT ADDRESS: Z- G I G e= -'`r' -AVE, BUILDING AREA: sq ft <br /> PROJECT TYPE: 0 NEW CONSTRUCTION 0 ADDITION 0 TENANT IMPROVMENT 0 REMODEL <br /> BUILDING USE: Q SFR 0 TOWNHOUSE 0 DUPLEX ❑ADU ❑ MULTI-FAMILY-#OF UNITS: 0 COMMERCIAL <br /> ELECTRICAL APPLICATION INFORMATION'S, DESCRIPTION OF WORK <br /> CONTRACT PRICE OF WORK:$ <br /> 5-56 G' ASSOCIATED BUILDING PERMIT#(if applicable): <br /> DESCRIBE SCOPE OF WORK: D6D^rG -C-o Lam' -3-T <br /> THIS INSTALLATION INCLUDES THE FOLLOWING SCOPE: (SELECT ALL THAT APPLY) <br /> LINE VOLTAGE WORK? ❑yy NO YES-Select Scope: 0 Service 0 Feeder 0 Circuits-#: 1 0 Complete Re-wire <br /> LOW VOLTAGE WORK? Wl1 NO 0 YES-#of Devices: <br /> SELECT SCOPE(REQUIRED): 0 Data 0 Intercom 0 Thermostat 0 Audio ❑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 /> CODE COMPLIANCE <br /> IS THIS PERMIT EDUCATION, INSTITUTIONAL,HEALTH AND/OR PERSONAL CARE FACILITIES: ® 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: NO OYES-See Below&Pg. 3 <br /> O 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: 1)( m }-lfl rn Mtn TENANT BUSINESS NAME(If Commercial): <br /> OWNER MAILING ADDRESS: STREET 7(:.41 .f yt t <br /> CITY �T� STATE 41 r+- ZIP 1 g-2.C`( <br /> OWNER PHONE:ILI ( 12 S Z OWNER EMAIL jam- C' ' ^1( <br /> .sL� Z OA��MC-Az- (--0`'n-C-n <br /> CONTRACTOR NAME: V- -mc' (T �-� <br /> CONTRACTOR ADDRESS: STREET I OL o 1 FAQ,04 -N M pt t= e P 1, <br /> CITY MT- V6,i2-J- STATE ,,,Jn ZIP ‘1S-2'VA <br /> CONTRACTORPHONELSi.0 3i%- CONTRACTOR EMAIL: ViA,-'OE-Q E! G0-1 I•'M <br /> CONTRACTOR LIC.#(REQUIRED): _y411'1S OL CITY OF EVERETT BUSINESS LIC.#(REQUIRED): OS ("1 1? <br /> PRIMARY CONTACT: DOWNER 0 CONTRACTOR 0 OTHER(Please Specify) <br /> CONTACT NAME: CONTACT PHONE: (t (U1 " 3 1 — 1 L S <br /> tDF c ) T f,L —{ A M ff 6 IL CONTACT EMAIL: <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 governing this <br /> type of ork 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 la regulating construction or the performance of construction. That I am authorized by the owner of this property to perform the C work <br /> Efor whi hich am Offiauthoriz <br /> Use Only is e and I <br /> co ly 'th the State Contractors Law 18.27 RCW and 296.200 WAC. <br /> PERMIT#: <br /> /11 E n-p9 <br /> Owner/Authorized Agent Signature Date (Revised 1/11/2019) Page 1-Application <br />