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0 <br /> ELECTRICAL PERMIT APPLICATION <br /> 4.-77- <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.govlpermits <br /> PROJECT SITE INFORMATION <br /> PROJECT ADDRESS: ` Z - I J CQAAA)A... BUILDING AREA: sq ft <br /> PROJECT TYPE: $NEW CONSTRUCTION ❑ADDITION! ❑TENANT IMPROVMENT ❑ REMODEL / <br /> BUILDING USE: CI SFR ❑ TOWNHOUSE CI DUPLEX ❑ ADU 1MULTI-FAMILY-#OF UNITS: 1 4, `, " •MMERCIAL <br /> ELECTRICAL APPLICATION INFORMATION & DESCRIPTION OF WOR <br /> CONTRACT PRICE OF WORK:$ 10'000, °' ASSOCIATED BUILDING PERMIT#(if applicable): �l <br /> DESCRIBE SCOPE OF WORK: �e,,oirn f u i y Q(�/1 -- ?I a b/z,77 iieI-f) -3 56 <br /> THIS INSTALLATION INCLUDES THE FOLLOWING SCOPE: (SELECT ALL THAT APPLY) <br /> LINE VOLTAGE WORK? ❑ NO ❑YES-Select Scope:PService ❑ Feeder ❑ Circuits-#: ❑ Complete Re-wire <br /> LOW VOLTAGE WORK? Mq10 ❑ YES-#of Devices: <br /> SELECT SCOPE(REQUIRED): ❑ Data ❑ Intercom ❑Thermostat ❑ Audio ❑ Secure Access ❑ 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 PERMIT EDUCATION,INSTITUTIONAL,HEALTH AND/OR PERSONAL CARE FACILITIES: ❑ NO El 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: ENO EYES-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 /> CONTA T INFO TION <br /> �n 3 Ame►rtcu>7 Nome 73:,�1 <br /> OWNER NAME: ;ir.-j p" a( Iv1QT( T NANT BUS N SS NAME(If Commercial): <br /> r .I <br /> OWNER MAILING ADDRESS:II 0sTR ET I j t° 4 A JL A J <c.t i t Q SSo <br /> ' t CIT( )3.e l IQ')1�.e, STATE f c)j�. , ZIPq*Set q <br /> OWNER PHONE: "TZS 7bCie-`7 Z`-TZin OWNER EMAIL: <br /> CONTRACTOR NAME: s%4-WQb / P�/ r /nC/Lef: ►' �C' <br /> CONTRACTOR ADDRESS:3V IO STREET ( t v A ZC , /1/� <br /> CITY Ay- I n STATE AM' ZIP p2Z3 <br /> CONTRACTOR PHONE:44 ZS -7ab---3 Li& ONTRACTOR EMAIL: (J- c.e. /►/Iarija e5 14eke.that c r c, c m <br /> CONTRACTOR LIC.#(REQUIRED);$I2c)k,PE9 33m 13 CITY OF EVERETT BUSINESS LIC.#(R QUIRED):(D L&5 g 7 <br /> PRIMARY CONTACT: DOWNER KtONTRACTOR ❑OTHER(Please Specify) <br /> CONTACT NAME: �J� CONTACT PHONE,Jd ( f u�r ti 1 <br /> C�1 W 11 CONTACT EMAIL:V YYIarl/neg ji,nr D/�/` ,,jr)C-oex,H'L <br /> AGREEMENT:I hereby certify that I have read and examined this application and know the same to be true and correct. All provisio 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 th State Contractors Law 18.27 RCW and 296.200 WAC. City of Everett Official Use Only <br /> t <br /> ,..e„,e) - - <br /> 3�i <br /> // PERMIT#: <br /> � l2 E la o(6- 1} 1 <br /> Owner/Authorized Agen ignature Date (Revised 1/11/2019) Page 1-Application <br />