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0 <br />19 <br />ELECTRICAL PERMIT APPUCATI® <br />EVEREIFT <br />WARHINC;TON <br />CITY OF EVERETT PERMIT SERVICES <br />3200 CEDAR STREET, EVERETT, WA 98201 <br />(P) 425-257-8810 1 FAX 425-257-8857 1 (E) everetteps@everettwa.gov I www.everettwa.gov/permits <br />PROJECT SITE INFORMATIONPROJECT <br />ADDRESS: S 0 G <br />BUILDING AREA: "' J ' �o'�'oi ft <br />PROJECT TYPE: atVV CONSTRUCTION ❑ ADDITION ❑ TENANT IMPROVMENT ❑ REMODEL <br />BUILDING USE: SFR ❑ TOWNHOUSE ❑ DUPLEX ❑ ADU ❑ MULTI -FAMILY - # OF UNITS: ❑ COMMERCIAL <br />ELECTRICAL APPLICATION INFORMATION & DESCRIPTION OF Wt'>`FRK <br />CONTRACT PRICE OF WORK: $ <br />ASSOCIATED BUILDING PERMIT # (if applicable): <br />DESCRIBE SCOPE OF WORK: L rLV` <br />THIS INSTALLATION INCLUDES THE FOLLOWING SCOPE: (SELECT ALL THAT APPLY) <br />LINE VOLTAGE WORK? [_1 NO ,-ES - Select Scope: El Service u Feeder ❑ Circuits-#: ' ❑ Complete Re -wire <br />LOW VOLTAGE WORK? ❑ NO P-YES- # of Devices: C <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: D 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: [I 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 1 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: .?_N _ L ��� - TENANT BUSINESS NAME (If Commercial): <br />OWNER MAILING ADDRESS: STREET <br />CITY STATE ZIP <br />OWNER PHONE: <br />OWNER EMAIL: <br />CONTRACTOR NAME: <br />n ^ t <br />CONTRACTOR ADDRESS: STREET C,01 <br />CITY S-m-f-i wco STATE ,J� ZIP T� �' (✓ <br />L `n isl <br />CONTRACTOR PHONE: " ( L ^ —,) I J <br />CONTRACTOR EMAIL: <br />CONTRACTOR LIC. #(REQUIRED): I tr. ` CITY OF EVERETT BUSINESS LIC. (REQUIRED): J f,• <br />PRIMARY CONTACT: ❑OWNER ONTRACTOR ❑OTHER (Please Specify) <br />CONTACT NAME: yam, <br />CONTACT PHONE: "1�"-'5 <br />CONTACT EMAIL: <br />AGREEMENT/ hereby certify that / have read and examined this application and know the same to be true and correct. Hu provisions or laws ana ordinances governing this <br />type of work will be completed whether specked 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/ <br />comply with the State Contractors Law 18.27 RCW and 296.200 WAC. City of Everett Official Use Only <br />PERMIT #: <br />Owner/Autho zed Agent Signature Date (Revised 1/1112019) Page 1-Applicatioq <br />