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im _ECTRICAL PERMIT APPL ATION
<br /> CITY OF EVERETT PERMIT SERVICES
<br /> EVERETT 3200 CEDAR STREET;EVERETT,WA 98201
<br /> WASHINGTON (P)425-257-8810 1 FAX 425-257-8857 I(E)everettepstCx)everettwa.gov I wwweverettwa.govipermits
<br /> PRO-7;joati l'ULP4P-OPOUVr;,I,L.,:;,]-:4;;.; :: 4'. 771•1'.:. -:it;;A::,,, ,,.4::. -4,,,,;,'
<br /> PROJECT ADDRESS:cicuoc) ath AVG. '‘A i ,„ ..)1,0-e..t-k Guy...i. BUILDING AREA: ,ZOC 0 sq ft
<br /> PROJECT TYPE: LI NEW CONSTRUCTION El ADDITION ATENANT IMPROVMENT El REMODEL
<br /> BUILDING USE: El SFR 0 TOWNHOUSE Ell DUPLEX El ADU I% MULTI-FAMILY-#OF UNITS: l, E] COMMERCIAL
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<br /> CONTRACT PRICE OF WORK:$ 1,500,no ASSOCIATED BUILDING PERMIT#(if applicable):
<br /> DESCRIBE SCOPE OF WORK: Acce-y3 cor)troi, vvrecirot-viorl C-Cr- e kierl cr
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<br /> THIS INSTALLATION INCLUDES THE FOLLOWING SCOPE: (SELECT ALL THAT APPLY)
<br /> LINE VOLTAGE WORK? ill'4 NO CI YES-Select Scope: CI Service E Feeder 7 Circuits-#. CI Complete Re-wire
<br /> LOW VOLTAGE WORK? El NO s„,YES-#of Devices: t ,x
<br /> SELECT SCOPE(REQUIRED): ETI Data LI Intercom 0 Thermostat 0 Audio 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 /> EI Other(List All):
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<br /> IS THIS PERMIT EDUCATION,INSTITUTIONAL, HEALTH AND/OR PERSONAL CARE FACILITIES: 02 NO U YES--See Below&Pg.2
<br /> .---- ,0' By checking this box,I am stating that I have read and understand all of WAC 296-46B-9i 1,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 OWNER PERFORMING WORK AS THE CONTRACTOR WITHOUT ELECTRICAL LICENSURE: 40 OYES-See Below&Pg.3
<br /> ii 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.
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<br /> OWNER NAME: bre,,--\—-TA "\§F. timitn ctrafENANT BUSINESS NAME(If Commercial):
<br /> OWNER MAILING ADDRESS: STREET cy)C23 5 . Us)CA.0 1---. 0 9‘ 4,,, TE 1-1,...400
<br /> C.:km Lac)LI city MI STATE LO CIL,O(. .,) zip
<br /> OWNER PHONE: OWNER EMAIL.
<br /> CONTRACTOR NAME:'7%:„Irri C\j(1,,,*1 ve '..s..„,,i.S --v-ei_
<br /> CONTRACTOR ADDRESS: STREET tqa), tny......4) Tows y -A .E-- I 64
<br /> L.Cikv Tekvy s CITY WI:4)i STATE Qs-0 cp ZIP
<br /> CONTRACTOR PHONE:L)53 gen J(2.9 (p CONTRACTOR EMAIL:Dc41(..Q e -, 5-3/4c- — c".5e ,c, tiry1,
<br /> CONTRACTOR LIC.ft(REQUIRED) r\PS'T.51 k bi—k CITY OF EVERETT BUSINESS LIC.#(REQUIRED): 5315..
<br /> PRIMARY CONTACT: DOWNER ONTRACTOR OTHER(Please Specify)
<br /> CONTACT NAME: CONTACT PHONE: -4390 - -1 ICI S'
<br /> .114:• ..,—"Icke,4_ , CONTACT EMAIL:/A 0,41 e Vs - — it se cur\
<br /> AGREEMENT:I hereby certify that I have read and examined this application and know the same to be true and correct, Ali 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, Thai I am authorized by the owner of this properly to perform the work for which application is made and I
<br /> comply with the State Contractors Law 1817 RCW and 296.200 WAC. City of Everett Official Use Only
<br /> PERMIT#:
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<br /> t zedAgenkignature Date (Revised 111112019) Paget-Application
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