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1112 ELECTRICAL PERM IIT r PPS..OCATI N <br /> V T T 32CITY OF EVERETT PERMIT SERVICES <br /> 00 CEDAR STREET, EVERETT,WA 98201 <br /> WASHINGTON (P)425-257-8810 I FAX 425-257-8857 I(E)everetteps@everettwa.gov I www.everettwa.gov/permits -- <br /> PROJECT SITE INFORMATION . <br /> PROJECT ADDRESS: 6 A ck r,•t _} /�+ \; C BUILDING AREA al\-] sgf❑�rs <br /> PROJECT TYPE: Ii NEW CONSTRUCTION ❑ADDITION ❑TENANT IMPROVMENT ❑ REMODEL <br /> BUILDING USE: 'Hi-SFR ❑ TOWNHOUSE ❑ DUPLEX ❑ADU ❑ MULTI-FAMILY-#OF LFPII�S:� COMMERCIAL <br /> ELECTRICAL APPLICATION INFORMATION & DESCRIPTION OF WORK <br /> CONTRACT PRICE OF WORK: $ I Z� l�i " 0 <br /> ASSOCIATED BUILDING PERMIT#(if applicable): <br /> DESCRIBE SCOPE OF WORK: (/`) t C /\\:, <br /> f V� <br /> THIS INSTALLATION INCLUDES THE FOLLOWING SCOPE: (SELECT ALL THAT APPLY) <br /> LINE VOLTAGE WORK? ❑ NO YES-Select Scope: 'Service ❑ Feeder ❑ Circuits-#: ❑ Complete Re-wire <br /> LOW VOLTAGE WORK? ❑ NO RYES-#of Devices: <br /> SELECT SCOPE(REQUIRED): ❑ Data ❑ Intercom 71Thermostat ❑ 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): <br /> CODE COMPLIANCE <br /> IS THIS PERMIT EDUCATION, INSTITUTIONAL, HEALTH AND/OR PERSONAL CARE FACILITIES: .t^t NO ❑ 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: O EYES-See Below&Pg. 3 <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. <br /> CONTACT INFORMATION <br /> OWNER NAME: }--j =i ) 11e,\ a `- S TENANT BUSINESS NAME(If Commercial): <br /> OWNER MAILING ADDRESS: STREET <br /> CITY i STATE ZIP <br /> OWNER PHONE: OWNER EMAIL: ` \ <br /> - •� q ?j} <br /> CONTRACTOR NAME: \ moi✓ < <br /> CONTRACTOR ADDRESS: STREET HO.1 13 I I �5+ \r (� V <br /> 4 i- STATE -- �� ZIP <br /> CONTRACTOR PHONE: CONTRACTOR EMAIL: <br /> CONTRACTOR LIC.#(REQUIRED):j c O ElL i_ , ) C-3 CITY OF EVERETT BUSINESS LIC.#(REQUIRED): <br /> PRIMARY CONTACT: DOWNER ACONTRACTOR ❑OTHER(Please Specify) <br /> CONTACT NAME: (� � 3l CONTACT PHONE: C� Z `Z L{ �- LO <br /> . ( <br /> n o i�0� " N,` C „1 CONTACT EMAIL: IAZri <� pre.) /L L b — l`; Vit c e <br /> AGREEMENT:1 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 wile co •leted 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 regu:hng c,,nstruction 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 e St. e Contractors Law 18.27,RCW and 296.200 WAC. City of Everett Official Use Only <br /> /411 <br /> PERMIT#: <br /> ��- J uw� 3 � E \skoc -- Do <br /> oir...rite.Agent Signature Date (Revised 1/11/2019) Page 1-Application <br />