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9 It <br />ELECTRICAL PERMIT APPLICATION <br />CITY OF EVERETT PERMIT SERVICES <br />EVERETT 3200 CEDAR STREET, EVERETT, WA 98201 <br />WASHINGTON (P) 425-257-8810 1 FAX 425-257-8857 1 (E) everetteps@everettwa.gov I wvvw.everettwa.gov/permits <br />PROJECT SITE INFORMATION <br />PROJECT ADDRESS: <br />BUILDING AREA: sq ft <br />PROJECT TYPE: ❑ NEW CONSTRUCTION ❑ ADDITION ❑ TENANT IMPROVMENT ❑ REMODEL <br />BUILDING USE: ❑ SFR ❑ TOWNHOUSE ❑ DUPLEX ❑ ADU ❑ MULTI -FAMILY - # OF UNITS: COMMERCIAL <br />ELECTRICAL APPLICATION INFORMATION .& DESCRIPTION 1OF:WORK <br />CONTRACT PRICE OF WORK: $ J S(iCz "— <br />ASSOCIATED BUILDING PERMIT # (if applicable): <br />DESCRIBE SCOPE OF WORK: ���1dw: ► <� — f=i �c r� ( i�c C, f c <br />THIS INSTALLATION INCLUDES THE FOLLOWING SCOPE: (SELECT ALL THAT APPLY) <br />LINE VOLTAGE WORK? %0 ❑ YES - Select Scope: ❑ Service ❑ Feeder ❑ Circuits-#: ❑ Complete Re -wire <br />LOW VOLTAGE WORK? ❑ NO ❑ 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 />CODECOMPLIANCE <br />IS THIS PERMIT EDUCATION, INSTITUTIONAL, HEALTH AND/OR PERSONAL CARE FACILITIES: 7 NO 71 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: ❑NO ❑YES 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: t, - -( nevi t: _- • TENANT BUSINESS NAME (If Commercial): <br />OWNER MAILING ADDRESS: STREET <br />CITY I�LvI Yi.+� STATE 1", ZIP <br />OWNER PHONE: <br />OWNER EMAIL: <br />CONTRACTOR NAME:LC—�— <br />CONTRACTOR ADDRESS: STREET5 �l !tom = 5 <br />i <br />CITY SecrTl C STATE tJ14 ZIP <br />CONTRACTOR PHONE: __Lt. `t St; `i t ic: <br />CONTRACTOR EMAIL: <br />CONTRACTOR LIC. #(REQUIRED): 1r'r f,c_A C G- i ;b41(� <br />CITY OF EVERETT BUSINESS LIC. #(REQUIRED): GCI �' <br />PRIMARY CONTACT: ❑OW ......_ . _ �, ...... au . � ... <br />NER ❑CONTRACTOR OTHER Please Sp eci VA_✓► <br />Specify) <br />CONTACT NAME: I <br />CONTACT PHONE: <br />CONTACT EMAIL: <br />AGREEMENT: I hereby certify that/ have read and examined this application and know the same to be true and correct. Hn provisions or taws and ordwanuus yuvemuiy uns <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 1 <br />comply with the State Contractors Law 1827 RCW and 296.200 WAC. City of Everett Official Use Only <br />PERMIT #: <br />0IJ � ((z ,, E �61 <br />Ow er/Auth rized AhbVit Signature Date (Revised 111112019) Page1 -Application <br />2 <br />