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• <br /> mum <br /> ElFCTRlCAL PERMIT APPLONT1ON <br /> EVERETT CITY OF EVERETT PERMIT SERVICES <br /> 3200 CEDAR STREET,EVERETT,WA 98201 <br /> WASHINGTON (P)425-257-8810 I FAX 425-257-8857 I(E)everetteps@everettwa.gov I www.everettwa.gov/permits <br /> /I�PROJECSITE INFORMATION <br /> PROJECT ADDRESS: 17 cl b`Z ,QY�' t�Na(4:t( -WM- ( BUILDING AREA: sq ft <br /> PROJECT TYPE: ❑NEW CONS I h2UCTION El ADDITION ❑TENT IMPROVMENT ❑REMODEL <br /> BUILDING USE: ❑SFR ❑TOWNHOUSE ❑ DUPLEX 17 ADU ❑MULTI-FAMILY-#OF UNITS: cf3COMMERCIAL <br /> ELECTRICAL APPLICATION INFORMATION'A DESCRIPTION OF WORK <br /> CONTRACT PRICE OF WORK: $ ASSOCIATED BUILDING PERMIT#(if applicable): <br /> DESCRIBE SCOPE OF WORK: .444 4tc "p p_� <br /> �I <br /> C'-t"., _T P0-1 /1.t C y ya. <br /> THIS INSTALLATION INCLUDES THE FOLLOWING SCOPE: (SELECT ALL THAT APPLY) <br /> LINE VOLTAGE WORK? fl NO ❑YES-Select Scope:❑Service ❑ Feeder ❑ Circuits-#: n Complete Re-wire <br /> LOW VOLTAGE WORK? ❑ NO -YES-#of Devices: C-t <br /> SELECT SCOPE(REQUIRED): ❑ Data ❑ Intercom El 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 /> 5LOther(List All): C— <br /> CODE COMPLIANCE. <br /> IS THIS PERMIT EDUCATION, INSTITUTIONAL, HEALTH AND/OR PERSONAL CARE FACILITIES: CI NO CI YES--See Below& Pg.2 <br /> I I 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,1(ES-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 /> CONTACT INFORMATION <br /> OWNER NAME:{ AA ( .-- <br /> 4.1j TENANT BUSINESS NAME(If Commercial): cgp_AAAt.0(2 3► J', by <br /> OWNER MAILING ADDRESS: STREET I ZqO 2_ P g ( top -f ti riA <br /> c, <br /> crry Al STATE (1)1 ZIP cp a 7_ <br /> OWNER PHONE: OWNER EMAIL: U <br /> CONTRACTOR NAME: Sri 4,, <br /> (' <br /> CONTRACTOR ADDRESS: STREET 2_9., q j �j�j Y" 41 j , >E,CITYo- ' 7 STATE ZIP <br /> 1111 TTT����"'' � <br /> CONTRACTOR PHONE: W ZS -- L(4g .-CZ•7 ] CONTRACTOR EMAIL: (� <br /> CONTRACTOR LIC.#(REQUIRED):s r,�i G s M C,O 3 L C1 CITY OF EVERETT BUSINESS LIC.#(REQUIRED): CJ, 60 <br /> PRIMARY CONTACT: DOWNER ECONTRACTOR MITHER(Please Specify) _ ^ . <br /> CONTACT NAME: Tom) L CONTACT PHONE: (fie) j1hqf�_ia�t3ci <br /> (, JC-CONTACT EMAIL: l � <br /> �• �l C� I ��-- 1��1�G�t,�� � �mac. <br /> AGREEMENT:I hereby certify that I have read and examined this application and know the same to be tr and correct. I i provisionsibf 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 l 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 /> NtRMII It: <br /> 2 ` Elo62 -2Z� <br /> wnerf th zed A t Signature Date- (Revised 1/11/2019) Page pplication \' <br />