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ELECTRICAL PERMIT APPLICATION <br /> • <br /> R T CU Y OF EVERETT PERMIT SERVICES <br /> EVEE T t3240 CEDAR STREET.EVERETT,'WA 98201 <br /> wAsrersraree (P)425-251-8810 I FAX 425=251480 1(E)everetletWIlleVereltweIlev I wwWevereftwagovIperrnits <br /> PROJECT ADDRESS: 2301 Virginia'AVE Everett 98201 EIJILDING AREA 89 it <br /> PROJECT TYPE 0 NEW CONSTRUCTION El ADDITION Q TENANT'IMPROVMENT 0 REMODEL <br /> BUILD1NG.USE 0 SFR 0 TOWNHOUSE 0 DUPLEX D ADU 0 MULTI-FAMILY°•#OF.UNITS: D COMMERCIAL <br /> C r`; ►.., , 1±1FORNAATIO, : 114th OF. TO <br /> CONTRACT PRICE OF WORK:s.1800 ASSOCIATED ammo'PERMIT#(if applicable): <br /> DESCRIBE SCOPE OF WORK:, <br /> 200 arrtp panel change,grounding.and bonding <br /> THIS INSTALLATION INCLUDES THE FOLLOWING SCOPE:(SELECT ALL THAT APPLY) <br /> LINE VOLTAGE WORK? 0 NO O YES-Select Scope:0 Service 0 Feeder 0 Circuits- : 0 Compteie.Re-wire <br /> LOW VOLTAGE WORK? 0 NO 0 YES-#of-Devices: <br /> SELECT SCOPE(REQUIRED):0 Data 0 Intercom 0 Thermostat 0 Audio 0 Secure Access0 Security system <br /> 0 Fire Alarm-:Insfallationt under this permit only indu te.electricat wiring rough-in of the system.An additional <br /> Fire Alarm Permit is required for review of devicelocalion and installation approval.; <br /> ❑Other{LIstAll): <br /> _� �� • .. .. st - O w - a• <br /> is THIS PERMITEDUCATION,INSTITUTIONAL,HEALTt'I ANDLOR PERSONAL CARE FACILITIES NO I YES. See Setow <br /> By checidng;this-box,I am stating that I have read>and understand alt"of WAC• B=900,setec ed th a specific reason on page 2" <br /> ( .ol of this:application(see next page),ANDFlan Review is NOT requiredbecause.l meet all.of the following sub sea:meth*do not <br /> See Page 2 require Plan.Review.. <br /> / <br /> ARE YOU AN OWNER PERFORMING WORK AS THE CONT.I C'TOR WITHOUT &ELECTRICAL LICENSUREt ONO DYES-Seellelow <br /> DPursuant-to RCW 19.28.261,property owners and leaseholders.cannot perform electricalwcrit on buildings far rent;sale,orIease <br /> without the:ptoperelectrical 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 ofthis application to receive an exemption from this ircensingtcertificatiof requirement: <br /> - <br /> OWNER NAME.Brett Rogers , TENANT' BUSINESS NAM '{ITCommatt;tai) <br /> OWNERMAILING ADDREss! sTREEr 2301 Virginia AVE <br /> 'env Everett. swa W:$ z,a 98201 <br /> OWNER PHONE na OWNER emu Pa <br /> t;Or!ICRACTIwfR.AtAME: I ..o.a�_�� �.� <br /> n House Electrical Services, Ino: <br /> CONTRACTOR ADDRESS: snacr1580117th OR SE <br /> aly Lake Stevens trrwWA 4,98258 <br /> CONTRACTOR PHONE:425760 203 [CONTRACTOR:EMAILtiheperrnitsl grrlali.Corn; <br /> CONTRACTOR-LIC.#(REQUIRED): '►hodeS952tlg JCITY OF EVERETT BUSINESS LIC #CREDIARECt04168 <br /> „ n <br /> PRIMARY CONTACT: 'DOWNER ✓3CQNTRACTOR QOTiiER(Please'Speafy). <br /> CONTACT NAME: CONTACTPHONE:4253209149 <br /> • Kelsey CONTACt'EMAIL:ketsey@mfiotfs elet Ti .tolxt <br /> AGREEMENT:I boobycertify'that 1 lowo,coo0 257ax in n9rtthis ffppiicatIon arid know the same to 4aWe en(f"tie°t. AApm nsof fiend oft' anees°90 g this <br /> type of wor*will be camploter#w( tf+e sped Iedh n. not. The grantingofa pemlttddoes not mewing fo-Ovoitutholitytai#010 ortatzeOf th0provisions 5fally¢QTerstafa.or <br /> local law regula r ,construction-.or bre perfonnan• of onshuctIon. That f am authwiaed by the ownerathispn# rty to:porlorrmtho wask for***wilt:t on l med.snd.I <br /> complywlth-' :to Con,-ctorsLaw f8.27 R '': . `200 WPIC. City ofEyerettOfficial llse:ontp <br /> PERMIT#. <br /> ckoq <br /> Owns •sized :. Signature Date (Revfsed 17f/,2019)' Page 1,Appucation <br /> Scanned with CamScanner <br />