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ELECTRICAL PERMIT APPLICATION <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: 3 9 / M 3-S&el A BUILDING AREA: sq ft <br /> PROJECT TYPE: 0 NEW CONSTRUCTION 0 ADDITION 0 TENANT IMPROVMENT ® REMODEL <br /> BUILDING USE: ®SFR 0 TOWNHOUSE 0 DUPLEX 0 ADU ❑ MULTI-FAMILY-#OF UNITS: 0 COMMERCIAL <br /> ELECTRICAL APPLICATION INFORMATION &:DESCRIPTION OF WORK <br /> CONTRACT PRICE OF WORK:$ .-q a C` ASSOCIATED BUILDING PERMIT#(if applicable): <br /> DESCRIBE SCOPE OF WORK: REP L-.6,1C_' F_)CS(SY( Y-JC.w , roti? "(\ ��K3r L-.c2-• <br /> !X111 i I.4- OE, cve,404 4— ��YJ s�lZ <br /> THIS INSTALLATION INCLUDES THE FOLLOWING SCOPE: (SELECT ALL THAT APPLY) <br /> LINE VOLTAGE WORK? 0 NO DYES-Select Scope: ®Service 0 Feeder 0 Circuits-#: 0 Complete Re-wire <br /> LOW VOLTAGE WORK? ®NO 0 YES-#of Devices: <br /> SELECT SCOPE(REQUIRED): 0 Data 0 Intercom 0 Thermostat 0 Audio 0 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: J 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:j?(Nk4* j uat4TURK L.c-L TENANT BUSINESS NAME(If Commercial): <br /> OWNER MAILING ADDRESS: STREET <br /> CITY EVA<67— <br /> STATE ZIP <br /> OWNER PHONE: `(25 3 l9 OWNER EMAIL <br /> CONTRACTOR NAME: 14 c:C7(N( y '17- GTR•(L . l 1 C- <br /> CONTRACTOR ADDRESS: STREET T3.5 (/ C,,`/3.57 5 7,5r( �Z 1— S <br /> L= <br /> CITY vL'I•C ^/;(9T` STATE 0.3 4 ZIP ?e2-4S( <br /> CONTRACTOR PHONE: t12 ) 3C -C ; CONTRACTOR EMAIL: R ,( , K G_t CratC c CCi-•A(L_ <br /> CONTRACTOR LIC.#(REQUIRED): i`1Wtt.?EC.oG3N J CITY OF EVERETT BUSINESS LIC.#(REQUIRED): O 3 3‘{CS <br /> PRIMARY CONTACT: 0 OWNER ®.CONTRACTOR 0 OTHER(Please Specify) <br /> CONTACT NAME: CONTACT PHONE: f As 3 c _ 6,1 3 <br /> tY?r,K;C K (1,17X CONTACT EMAIL: 5 <br /> AGREEMENT.'I hereby certify tha(/l 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 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 - - /P E �9o( -- \L5 <br /> O .nerf•uthorized re tignature Date (Revised 1/11/2019) Page 1-Application <br />