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1111 ELECTRICAL PERMIT APPLICATION <br /> EVERETT 32 CITY OF EVERETT PERMIT SERVICES <br /> 00 CEDAR STREET,EVERETT,WA 98201 <br /> WASHINGTON (P)425-257-8810 I FAX 425-257-8857 (E)everetteps©everettwa.gov I www.everettwa.gov/permits <br /> PROJECT SITE INFORMATION <br /> PROJECT ADDRESS: 32/L 1?Cc) 1 ,1 All /r( 'Z BUILDING AREA: 3® 2 S z - sq ft <br /> PROJECT TYPE: IEW CONSTRUCTION ❑ADDITION El TENANT IMPROVMENT ❑ REMODEL <br /> BUILDING USE: ❑SFR ❑ TOWNHOUSE ❑ DUPLEX El ADU ❑ MULTI-FAMILY-#OF UNITS: [-COMMERCIAL <br /> ELECTRICAL APPLICATION INFORMATION B;-DESi_CRIPTION:OF`.WORK <br /> CONTRACT PRICE OF WORK:$ 1 2 S; c0 p 6.G 0 ASSOCIATED BUILDING PERMIT#(if applicable): <br /> DESCRIBE SCOPE OF WORK: J LQ e e 4 b( 14./ <br /> THIS INSTALLATION INCLUDES THE FOLLOWING SCOPE: (SELECT ALL THAT APPLY) <br /> LINE VOLTAGE WORK? LINO ❑YES-Select Scope: ❑Service El Feeder ❑ Circuits-#: El Complete Re-wire <br /> LOW VOLTAGE WORK? El NO ©TES-#of Devices: 41Z0 <br /> SELECT SCOPE(REQUIRED): {6ata ❑ Intercom ❑Thermostat ❑Audio El Secure Access El 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: Ef1iO 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: 2140 EYES-See Below&Pg.3 <br /> fI 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 /> CONTACT INFORMATION, _ <br /> OWNER NAME: 3 Z • 11 y 1 f2T S TENANT BUSINESS NAME(If Commercial): 3 Z arc Aclku4N, 1A-PA.%2.74,44,t3 <br /> OWNER MAILING ADDRESS: STREET�(/DI-- 1)4 /\UC. N C S(_t/T-0 -S S D <br /> CITY &-f2 I 1-Q 1 Li ( STATE L.,: Cs._ ZIP c'/)0 C� <br /> OWNER PHONE: OWNER EMAIL: <br /> CONTRACTOR NAME: C t Jai 112 M-f 1u0 LI c"}\ Ili rt l !!�r S t ( <br /> CONTRACTOR ADDRESS: STREET I I(�) a T S T S <br /> CITY /'`Q'pA (,) STATE Lk. C ZIP 9O) ,jL(- `( <br /> CONTRACTOR PHONE: 3 3 3o 3 a b S lP CONTRACTOR EMAIL: A-CI 4 l2 e e L IS t 2 A.14 ru.,c e./C ,SOT 144 S,C13 <br /> CONTRACTOR LIC.#(REQUIRED): t RAJ g ? ZUti P CITY OF EVERETT BUSINESS LIC #(REQUIRE • O <br /> PRIMARY CONTACT: DOWNER UCONTRACTOR ❑OTHER(Please Specify) <br /> CONTACT NAME: CONTACT PHONE: 2 5 3-- ) ' '- 2(Q S(-c <br /> 3tvn I(2- CONTACTEMAIL:``f-1 tr2 €) L4-„tt►2 (`U('.Z((Solkf7/I-tJS• C0:rt <br /> AGREEMENT:I hereby certify that 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 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 1 am authorized by the owner of this property to perform the work for which application is made and I <br /> comply with the State Contractors Law 18.27 RCW and 296.200 WAC. City of Everett Official Use Only <br /> PERMIT#: <br /> E V9.0% 4C0Ck <br /> Owner/Au rized Agent Signature Date (Revised 1/11/2019) Page 1-Application <br />