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<br /> ELECTRICAL PERMIT APPLICATION
<br /> CITY OF EVERETT PERMIT SERVICES
<br /> EVERETT 3200 CEDAR STREET,EVERETT,WA 98201
<br /> WASHIUGTON (P)425-257-8810 I FAX 425-257-8857 1(E)everetteps@everettwa.gov( www.everettwa.gov/permits
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<br /> PROJECT ADDRESS: Li( 2 IFINEMILMEIMMII BUILDING AREA: sq ft
<br /> PROJECT TYPE: ❑ NEW CONSTRUCTION ❑ADDITION �TENANT IMPROVMENT ❑ REMODEL
<br /> BUILDING USE: ❑SFR ❑TOWNHOUSE ❑ DUPLEX ❑ADU ❑ MULTI-FAMILY-#OF UNITS: .ri COMMERCIAL
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<br /> CONTRACT PRICE OF WORK:$ 00G•(10 ASSOCIATED BUILDING PERMIT#(if applicable):
<br /> DESCRIBE SCOPE OF WORK: iii., A. ,,.J0 4 Ar 4 ,
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<br /> THIS INSTALLATION INCLUDES THE FOLLO ING SCOPE: (SELECT ALL THAT APPLY)
<br /> LINE VOLTAGE WORK? ❑NO 1 YES-Select Scope:El Service El Feeder ❑Circuits-#: ' ❑Complete Re-wire
<br /> LOW VOLTAGE WORK? ❑NO ❑YES-#of Devices:
<br /> SELECT SCOPE(REQUIRED): ❑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): 9
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<br /> IS THIS PERMIT EDUCATION,INSTITUTIONAL,HEALTH AND/OR PERSONAL CARE FACILITIES: —� NO • YES--See Below&Pg.2
<br /> E 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 LICENSUR oil NO EYES-See Below&Pg.3
<br /> ❑
<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.
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<br /> OWNER NAME: TENANT BUSINESS NAME If Commercial):. r Ir,
<br /> OWNER MAILING ADDRESS: STREET
<br /> CITY STATE ZIP
<br /> OWNER PHONE: OWNER ' :-v(��
<br /> EMAIL:
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<br /> CONTRACTOR NAME: ISMIIIM
<br /> CONTRACTOR ADDRESS: STREETS O �� � 4,31.111111111.11111111111.111.1111..
<br /> iiiiiiiMMEN w, ct &i._.. ` STATE lt- ZIP l
<br /> CONTRACTOR PHONE: 2(4) '7. ( - I CONTRACTOR EMAIL: Ilk,_Ai / ( 1 ' 2.- . ' (•co
<br /> CONTRACTOR LIC.#(REQUIRED): ►� _;�: i/T CITY OF EVERETT BUSINESS LIC.#(REQUIRED): • c-S0`�
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<br /> PRIMARY CONTACT: [DOWNER s1 CONTRACTOR ❑OTHER(Please Specify)
<br /> CONTACT NAME: CONTACT PHONE: v-- 2– " l 2_
<br /> \tcji- h A Ci CONTACT EMAIL: Ill 1 ‘ 'it.— ' . 0-•• 1 /2 0 MITE
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<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 work will be completed whether specked 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 lam 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#:
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<br /> 04-6j2$4--
<br /> 0 ••uthorized Agent Signature Date (Revised 1/11/2019) r Page 1 Applicatio
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