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ELECTRICAL PERMIT APPLICATION <br /> CITY OF EVERETT PERMIT SERVICES <br /> ' 10.!"""4 <br /> ,44 3200 CEDAR STREET, EVERETT,WA 98201 <br /> �� (P)425-257-8810 I FAX 425-257-8857 1(E)everetteps@everettwa.gov I www.everettwa.gov/permits <br /> PROJECT SITE INFORMATION <br /> PROJECT ADDRESS: i..1 /0 3 ' BUILDING AREA: sq ft <br /> PROJECT TYPE: 0 NEW CONSTRUCTION 0 ADDITION 0 TENANT IMPROVMENT IgtREMODEL <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:$ 0 ASSOCIATED BUILDING PERMIT#(if applicable): <br /> DESCRIBE SCOPE OF WORK: Pti t e. (IQ 67(OVA./67 F 14-Flz-s i/U r'1 A-)c ..' fie <br /> FlovKLr Int +4X e1L„ <br /> THIS INSTALLATION INCLUDES THE FOLLOWING SCOPE: (SELECT ALL THAT APPLY) / <br /> LINE VOLTAGE WORK? 0 NO ®YES-Select Scope: %% Service 0 Feeder 0 Circuits-#: /(C 0 Complete Re-wire <br /> LOW VOLTAGE WORK? ® NO 0 YES-#of Devices: <br /> SELECT SCOPE(REQUIRED): ❑Data 0 Intercom 0 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 /> ❑Other(List All): <br /> • CODE COMPLIANCE . <br /> IS THIS P MIT 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: NO DYES-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:CLi►') ?gce' ry.5ctirrtew5 U.'- TENANT BUSINESS NAME(If Commercial): <br /> OWNER MAILING ADDRESS: STREET 1 Lj 75-/ f / ei5 ) ST Sit 1 U _ 67 __ <br /> 2 e CITY i Itf e �'r <br /> ^ STATE \ ZIP q ( v <br /> OWNER PHONE 40(� J 1 b �Q-7 Le OWNER EMAIL: <br /> CONTRACTOR NAME: tom--eNrr'fl- E ctV L. <br /> CONTRACTOR ADDRESS: STREET L[1`61(,Q I.FS Th V-e 56 <br /> CITY S,IL)( v%t( 5 STATE LA-)Pt ZIP CI 7€10 <br /> CONTRACTOR PHONE: CONTRACTOR EMAIL: ®� <br /> CONTRACTOR LIC.#(REQUIRED) Frek, ECL5S3�E .S CITY OF EVERETT BUSINESS LIC #(REQU ED) �V <br /> PRIMARY CONTACT: DOWNER ❑CONTRACTOR ❑OTHER(Please Specify) <br /> CONTACT NAME: e CL crCONTACT PHONE: 1.,40(0 590 3(Q ICP <br /> C CONTACT EMAIL: <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 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 /> r PERMIT#: <br /> ‘22-- °1 E 1.cl0q -- Cot-Ai <br /> Owne Authorized Agent Signature Date (Revised 1/11/2019) Page 1-Application <br />