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0 <br />L <br />ELECTRICAL PERMIT APPLICATION <br />CITY OF EVERETT PERMIT SERVICES <br />3200 CEDAR STREET, EVERETT, WA 98201 <br />(P) d95_957_RR1n I FAX 425-257-8857 1 (E) everettegs(cDeverettwa.gov I www.everettwa.gov/permits <br />PROJECT SITE INFORMATION <br />nn <br />PROJECT ADDRESS: kw Z t k,' e j d <br />BUILDING AREA: sq ft <br />PROJECT TYPE: ❑ NEW CONSTRUCTION ❑ ADDITION b TENANT IMPROVMENT �EMODEL <br />BUILDING USE: ❑ SFR ❑ TOWNHOUSE ❑ DUPLEX DU ❑ MULTI -FAMILY - # OF UNITS: [I COMMERCIAL <br />ELECTRICAL APPLICATION INFORMATION & DESCRIPTION OF WORK, <br />CONTRACT PRICE OF WORK: $ <br />ASSOCIATED BUILDING PERMIT # (if applicable): <br />DESCRIBE SCOPE OF WORK: <br />e r , <br />THIS INSTALLATION INCLUDES THE FOLLOWING SCOPE: (SELECT ALL THAT APPLY) <br />LINE VOLTAGE WORK? ❑ NO❑YES - Select Scope: ❑ Service ❑ Feeder ❑ Circuits-#: ❑ Complete Re -wire <br />LOW VOLTAGE WORK? ❑ NO L(d/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 U 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 0 OWNER PERFORMING WORK AS THE CONTRACTOR WITHOUT ELECTRICAL LICENSURE: ❑NO 11YES -See Below & Pg. 3 <br />ErPursuant 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 />CONT1kCT. INFORMATION. <br />OWNER NAME: Y TENANT BUSINESS NAME If Commercial): <br />OWNER MAILING ADDRESS: STREET '2 r' "�'1/ 96 <br />CITY STATE ZIP <br />OWNER PHONE: OWNER EMAIL: <br />CONTRACTOR NAME: <br />CONTRACTOR ADDRESS: STREET <br />CITY STATE ZIP <br />CONTRACTOR PHONE: <br />CONTRACTOR EMAIL: <br />CONTRACTOR LIC. #(REQUIRED): ICITY OF EVERETT BUSINESS LIC. #(REQUIRED): <br />PRIMARY CONTACT: OWNER ❑ CONTRACTOR ❑ OTHER (Please Specify) <br />CONTACT NAME: <br />J <br />CONTACT PHONE: 2 .7 <br />CONTACT EMAIL: A^ L « � t et- nra�r at a-'r o L- <br />i nrnvisinns of taws and nr n aoveminq thls <br />AGKLLMLN t: I nereDy cernry rnar i nave reau anu—all ill — - apt, „ ,,,,, 4 ^^ • ­..- <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/ am authorized by the owner of this property to perform the work for which application is made and/ <br />comply with the State Contractors Law 18.27 RCW and 296.200 WAC. City of Everett Official Use Only <br />I/ I 1PERMIT #: <br />fr>l <br />E �c� o4 <br />Owner/Authorized Agent Si a ure Date (Revised 1/11/2019) Page 1-Application <br />