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ELECTRICAL PERMIT APPLI TION <br /> G V E R E T TCITY OF EVERETT PERMIT SERVICES <br /> 3200 CEDAR STREET,EVERETT,WA 98201 <br /> WASHINGTON (P)425-257-8810 j FAX 426-257-8857 I(E)everettepseverettwa.gov j www.everettwa.gov/permits <br /> PROJECT SITE INFORMATION <br /> PROJECT ADDRESS: ' 0 a. S)11,Lk,sam 4( BUILDING AREA: sq ft <br /> PROJECT TYPE: 0 NEW CONSTRUCTION 51ADDITION ❑TENANT IMPROVMENT 0 REMODEL <br /> BUILDING USE: 0 SFR 0 TOWNHOUSE D DUPLEX Cl ADU ❑MULTI-FAMILY-#OF UNITS: )112 COMMERCIAL <br /> ELECTRICAL APPLICATION INFORMATION & DESCRIPTION OF WORK <br /> CONTRACT PRICE OF WORK:$ 15,CM ` ----- ASSOCIATED BUILDING PERMIT#(if applicable): <br /> DESCRIBE SCOPE OF WORK: _5662th 3.( g55 (3) qo - Vic,,- - r, Y. Ailey <br /> THIS INSTALLATION INCLUDES THE FOLLOWING SCOPE: (SELECT ALL THAT APPLY) <br /> LINE VOLTAGE WORK? Q NO 12 YES Select Scope:0 Service D Feeder LE Circults-#;, S ❑Complete Re-wire <br /> LOW VOLTAGE WORK? 0 NO 0 YES-#of Devices: <br /> SELECT SCOPE(REQUIRED): ❑ Data D Intercom D Thermostat 0 Audio 0 Secure Access 0 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 /> 0 Other(List All) <br /> CODE COMPLIANCE <br /> IS THIS PERMIT EDUCATION,INSTITUTIONAL,HEALTH AND/OR PERSONAL CARE FACILITIES: L.?d'`>do ❑YES--See Below&Pg.2 <br /> [""' By checking this box,I am stating that I have read and understand all of WAC 298.6E-900,selected the specific reason on page 2 <br /> uj 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: DYES-See Below&Pg.3 <br /> Pursuant to ROW 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: TENANT BUSINESS NAME(if Commercial): Ttrtys Pre,il i 5sbt3 fibtititAt, Ei <br /> OWNER MAILING ADDRESS: STREET 1 l t . $it tkk...,AA) 01". <br /> CITY GS.(,1.(r( .. STATE 1,431. np gen/A <br /> OWNER PHONE: OWNER EMAIL: <br /> CONTRACTOR NAME: ``� 1AP�}P\)-`‘ <br /> CONTRACTOR ADDRESS: STREET i S t S ct(,>a t, <br /> CITY t t,,.+� ,,* STATE IA)lv ZIP 9 . 15., <br /> CONTRACTOR PHONE: i`1t.`3- -. 000 U CONTRACTOR EMAIL: ,,Vi �. r te ♦ r 11 . v Aloft. <br /> CONTRACTOR LIC.#(REQUIREQ): Sfiii.,SADELL,9115"- CITY OF EVERETT BUSINESS LIC.#4REQUlRED): 49(41.45 <br /> PRIMARY CONTACT: [DOWNER 21CONTRACTOR DOTHER(Please Specify) <br /> CONTACT NAME: CONTACT PHONE: 106-. 503.. <br /> i` •-C"-CvV`�c I fir. CONTACT EMAIL: 5c.o✓rr. at CP A) a • <br /> AGREEMENT:t hereby certify that I have read and examined this application and know the same to be true and correct. All pro lc sof 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 286,200 WAC. CI of Everett Official Use Ont <br /> V _ � PERMIT#: <br /> ,� o ,9 E t Ct 11 — 6 <br /> Owner/Authorized Ag:. Signatu , Date (Revised 1!11/2019) Pagepiicatlon <br />