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awn <br /> ELECTRICAL PERMIT APPLICATION <br /> CITY Or EVERETT PERMIT SERVICES <br /> EVERETT 3250 CEDAR STREET,EVERETT,WA 98201 <br /> WASHIN11704 (P)425-257-5810 FAX 425-257-8857 I(E)evarelfepePeveretlwa,gov I voew,everettwo,90vipefiniLs <br /> NFORAVOI*1 <br /> PROJECT ADDRESS: 3fl. 1.6rci "VC VO BUILDING AREA: sq ft <br /> PROJECT TYPE: Li NEW CONSTRUCTION El ADDITION El TENAN I IMPROVMEN A' REMODEL <br /> BUILDING USE: SFR El TOWNHOUSE 0 DUPLEX El ADU El MULTI-FAMILY- OF UNITS- El COMMERCIAL <br /> Iti , Led fl C: APPLICAAV rrOR <br /> CONTRACT PRICE OF WORK;$ isDO ASSOCIATED BUILDING PERMIT$(if appliceblei: <br /> DESCRIBE SCOPE OF WORK: GiVt.e.i C001 fvun. urifikaUt <br /> THIS INSTALLATION INCLUDES THE FOLLOWING SCOPE:(SELECT ALL THAT APPLY) <br /> LINE VOLTAGE WORK? n NO CI YES-Select Scope:U Service El Feeder Circuits-t/: I D Complete Re-wire <br /> LOW VOLTAGE WORK? Li NO [1]YES-#of Devices: <br /> SELECT SCOPE(REQUIRE131: El Data 4ntoragn El Thermostat 171 Audi. El 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 et device location and installation approval. <br /> El Other(List All): <br /> CODE COMPLJANCjIj A ,NA *AA,t: <br /> IS THIS PERMIT EDUCATION,INSTITUTIONAL,HEALTH AND/OR PERSONAL CARE FACILITIES: Eif NO 111 YES See Below&Pg.2 <br /> I Ry diecking 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 meat 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; IL NO OYES-See Below&Pg.3 <br /> fl <br /> Pursuant to ROW 10,28.261,property owners and leaseholders cannot perform electrical work on buildings for rent,sale,or lease <br /> 1 without the proper electrical ilcenSing and certification,or exemption.By checking this box,I am stating that I have completed and <br /> See Page'3 skilled the AFFIDAVIT on page 3 of this application to receive an exemption from this licensing/certification Toquimmont, <br /> TIL ,INFOR:MATIPSOA :•:::ATS. <br /> OWNER NAME: POPI 170/1)V1 TENANT BUSINESS NAME If Commercial : <br /> OWNER MAILING ADDRESS: soe-i.i 13VL "'LZ (4 Ave- <br /> CITY NTrit4 t STrrir. At2.0‘6 <br /> OWNER PHONE: 1.1514 1:14--ILO-AV OWNER EMAIL: PiarYI ea-trail @, corri <br /> CONTRACTOR NAME: PAUt f-tairYtit I-tail, I Air <br /> CONTRACTOR ADDRESS; STRCCT 1W.17 1,1.0441&tSINI <br /> CITY MOVVVIAkt raraCt s 7r qt,i0k-ki2 <br /> CONTRACTOR PHONE: ji 21 CONTRACTOR EMAIL; WirD(4 mut r1,41.W1,‘ C4eYirort <br /> CONTRACTOR LIC,#(REOLAREM: bLuefor-0-6-2...-1le...v.— CITY OF EVERETT BUSINESS LIC,It(REatilRED): UO-45 <br /> PRIMARY CONTACT: OWNER EICONTRACTOR 1:0TREN(Please Specify) <br /> CONTACT NAME: CONTACT PHONE; lap.2.-tt- 114f <br /> Rik WI PaAY 6'6 CONTACT EMAIL; ftm tio-traYl <br /> A GREEMENT;I hereby certrfy fixer f have mad end ofroariroud eppikefe.,,e end know Me&IMO to he bus and correct AO prrn.l.qenR of tows:m'on'omens noYneMn9 this <br /> type of wont itg.b9 exvriptetest eitiotw.RphatiJerf hereL,or"la The graMing of a pa mil does oaf pmelime to give euthotity to viaere or comoui theuy,',okins so'ony c,,ftfer state or <br /> local/ay/regularly rmArmorkin or the pt?rb,TrrTv. co 4.1kCoVnaturVon. Thai F am authodzed by(boomer of Ono pmperry ro perform the wirk tut eitkh op/Jiff:a:km iN made and I <br /> corn*veth the State Cmfraofore Lew 18 RCM,our?7.96,2M WAG. City of evolve Official Lire <br /> 'PERMIT#: <br /> j, - • <br /> E <br /> • <br /> OwnerlAirtheriiaa ant Signature Date (Revised WI/./20/Pi Page 1.4plication <br />