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ELECTRICAL PERMIT APPLIIC/ t'IIOO N <br /> / CITY OF EVERETT PERMIT SERVICES <br /> 3200 CEDAR STREET,EVERETT,WA 98201 <br /> (P)425-257-8810 I FAX 425-257-8857 I(E)everetteps@everettwa.gov I www.-everettwa.gov/permits <br /> PROJECT ADDRESS: tkii `' BUILDING AREA: sq ft <br /> \+� �t,'�.Nd \-t\10 �c�,1^:�� <br /> PROJECT TYPE: 01 NEW CONSTRUCTION 0 ADDITION 0 TENANT IMPROVMENT 0 REMODEL <br /> !BUILDING USE: ® SFR 0 TOWNHOUSE 00 DUPLEX 0 ADU 0 MULTI-FAMILY-#OF UNITS: 0 COMMERCIAL <br /> ELECTRICAL RICAL P 'LVGAT1 EG (]rw7 LTi€em "a EIESC tP T I ES Or WOR <br /> K 1 <br /> _ _ <br /> 'CONTRACT PRICE OF WORK:$ .O (ASSOCIATED BUILDING PERMIT#(if applicable): <br /> ;DESCRIBE SCOPE OF WORK: -Q, i . <br /> THIS INSTALLATION INCLUDES THE FOLLOWING SCOPE: (SELECT ALL THAT APPLY) <br /> LINE VOLTAGE WORK? 0 NO lig YES-Select Scope: ' Service 0 Feeder 0 Circuits-#: 0 Complete Re-wire <br /> LOW VOLTAGE WORK? 0 NO 0 YES-#of Devices: <br /> SELECT SCOPE(REQUIRED) <br /> D Data 0 Intercom 0 Thermostat 0 Audio 0 Secure Access 0 Security System <br /> 0 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 a <br /> r_ . .. ... . ,. ___..::.._ - _ �� �� YES See Below&Pg.2 <br /> IS THIS PERMIT EDUCATION,INSTITUTIONAL,HEALTH AND/OR PERSONAL CARE FACILITIES: NO <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 /> TARE YOU AN OWNER PERFORMING WORK AS THE CONTRACTOR WITHOUT ELECTRICAL LICENSURE: NO OYES-See Below&Pg. 3 <br /> l■ Pursuant to RCW 19.28.261,property owners and leaseholders cannot perform electrical work on buildings for rent,sale,or lease <br /> I 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 ImpoRmATtom <br /> OWNER NAME:`, tin`' TENANT BUSINESS NAME(If Commercial): <br /> OWNER MAILING ADDRESS: STREET <br /> CITY STATE ZIP _- <br /> OWNER PHONE:kkl,\ 17 ti $1J OWNER EMAIL: <br /> CONTRACTOR NAME: `l „rn x\.L %L.„, — <br /> Jrl ] <br /> CONTRACTOR ADDRESS: STREET `\14301 et kfirk �� � `nom �' � ZIP 1 � tiZ'� <br /> CITY �~`� ` - STATE v""` <br /> CONTRACTOR PHONE:'kL'S'L b '�1�C CONTRACTOR EMAIL: (A\)S IT--cre 'L�' t ` k - C )v‘ <br /> CONTRACTOR LIC.#(REQUIRED): OWS •4 • ';S'-.S 1 CITY OF EVERETT BUSINESS LIC.#(REQo -ED): • l„ • <br /> PRIMARY CONTACT: 0 OWNER K–CONTRACTOR 0 OTHER(Please Specify) <br /> CO T CT E: CONTACT PHONE: 12.5 <br /> 3L1.5-- qp 0 <br /> e6.1. Vt\, <br /> GS CONTACT EMAIL: <br /> AGREEMENT:I hereby certify t.at 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 w. will be completed hether 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 /> Iota ply re. latin. <br /> •coni cti to, the perform-. -of construction. That I am authorized by the owner of this property to perform the work for which application is made and I <br /> / /Law '. RCW and 296.200 ,C. City of Everett Official Use Only <br /> py PERMIT#: <br /> / ( • E ��, d2 - oo( <br /> 4 id <br /> Owner/Authori d Agent Signature Date (Revised 1/11/2019) Page 1-Application <br />