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aim <br /> tLECTRICAL PERMIT APPLICATION <br /> CITY OF EVERETT PERMIT SERVICES <br /> EVERETT 3200 CEDAR STREET,EVERETT,WA 98201 <br /> (P)425-257-8810 I FAX 425-257-8857 I(E)everetteps©everettwa.gov I www.everettwa.govipermits <br /> PROJECT ADDRESS: ZQ,10 Forest Vie44 Dr BUILDING AREA: sq ft <br /> PROJECT TYPE: 0 NEW CONSTRUCTION 0 ADDITION CI TENANT IMPROVMENT TfREMODEL <br /> BUILDING USE: SFR 0 TOWNHOUSE El DUPLEX 0 ADU El MULTI-FAMILY-#OF UNITS: El COMMERCIAL <br /> 3 tg4ifirlit:aEogigAmAppuoATKojtoir0RrviwnoN:,cosscRomfoptoEw000cigoksjbiVll% <br /> CONTRACT PRICE OF WORK:$ 1300 'ASSOCIATED BUILDING PERMIT#(if applicable): <br /> DESCRIBE SCOPE OF WORK: (k) OrCAAkt. -N( VOX\ ti Gjilt fiAtk,ikie 01A10,442 <br /> (t)' ii- for reA0c-Atin 12-) ,5vviiCkicS <br /> THIS INSTALLATION INCLUDES THE FOLLOWING SCOPE: (SELECT ALL THAT APPLY), <br /> LINE VOLTAGE WORK? EI,P [ 'ES-Select Scope:0 Service 0 Feeder 164-Circuits-#: '2-- 0 Complete Re-wire <br /> LOW VOLTAGE WORK? NO 0 YES-#of Devices: <br /> SELECT SCOPE(REQUIRED): El Data ID Intercom CI Thermostat El Audio 0 Secure Access El Security System <br /> El 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 /> Sf.11iall,t:lVaIW)-111*W;::"g4"lM4°LlE;4"PltIIAjf!::--Ailitr'Vl'l:'Elii.lMi;Ell7MlglllZ101NllFNW: <br /> IS THIS PERMIT EDUCATION,INSTITUTIONAL,HEALTH ANDIOR PERSONAL CARE FACILITIES: NO El YES--See Below&Pg.2 <br /> E 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: ENO DYES-See Below&Pg.3 <br /> r-- Pursuant to RCW 19.26.261, 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 /> NORNAITIONPMF;" <br /> OWNER NAME: Erfv4 TENANT BUSINESS NAME(If Commercial): <br /> OWNER MAILING ADDRESS: STREET it7IO F V'51.- tv\IOy <br /> CifY -6V-C/rcif STATE trNik ivel 2)2_09, <br /> OWNER PHONE: 11 & !OWNER EMAIL: r Pv <br /> CONTRACTOR NAME: ti/ OLAS \•C(rt.)40 <br /> CONTRACTOR ADDRESS: STREET clijO DY <br /> \c't <br /> cny WO, ,c-\TAttlA sTATENP‘ zp cW-2-refibi <br /> CONTRACTOR PHONE: 410 1(20 72.-0 [CONTRACTOR EMAIL: 0y110 'Oa/ <br /> CONTRACTOR LIC.#(REQUIRED): Il\) 0 R.0 CITY OF E RETT BUSINESS LIC.#(REQUIRED): Otit It Ctt <br /> • - <br /> PRIMARY CONTACT: [DOWNER CONTRACTOR DOTHER(Please Specify) <br /> CONTACT NAME: yemeil CONTACT PHONE: 40 I <br /> 2wo <br /> CONTACT EMAIL: nr../fRAr MCVS (2; TY)el <br /> AGREEMENT:I hereertIfy th- have read-nd examined this application and know the same to be true and correct. All pro Ions of laws and ordinances governing this <br /> type of 4!be corn eted ether specifie•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 regu ting coco structi'm or the performs ce of construction. That I em authorized by the owner of this property to perform the work for which application is made end I <br /> co •ly with t •Sta Cone ,ctors Law 1 27 R W and 296.200 WAC. City of Everett Official Use Only <br /> PERMIT*. <br /> /ID 1/0--)3 <br /> EDDI - 005 <br /> OwnertiX)4, orized Ag tit• nature \,.......„,Date (Revised 1111/2019) Page 1-Application <br /> //' <br />