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41 <br />Is <br />ELECTRICAL PERMIT APPLICATION <br />EVERETT <br />WASHIN6TnN <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 SITS INFORMATIQN ,:. <br />PROJECT ADDRESS: C- <br />BUILDING AREA: sq ft <br />PROJECT TYPE: ❑ NEW CONSTRUCTION ❑ ADDITION ❑ TENANT IMPROVMENT LWREMODEL <br />BUILDING USE: ❑ SFR ❑ TOWNHOUSE ❑ DUPLEX ❑ ADU ❑ MULTI -FAMILY - # OF UNITS: COMMERCIAL <br />ELECTRICAL APPLICATION INFORMATION A DESCRIPTIONVIF 1lIFORK <br />CONTRACT PRICE OF WORK: $�,00-? <br />ASSOCIATED BUILDING PERMIT # (if applicable): <br />DESCRIBE SCOPE OF WORK: ujg-t L <br />THIS INSTALLATION INCLUDES THE FOLLOWING SCOPE: (SELECT ALL THAT APPLY) <br />LINE VOLTAGE WORK? ❑ NO <br />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 />''CQDE COMPLIANCE;':.... .: <br />IS THIS PERMIT EDUCATION, INSTITUTIONAL, HEALTH AND/OR PERSONAL CARE FACILITIES: KNO YES -- See Below & Pg. 2 <br />❑ By checking this box, I am stating that I have read and understand all of WAC 296-4613-900, 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 DYES -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: 6-%5-M GW I Tt­ LWItIENANT BUSINESS NAME (If Commercial): <br />OWNER MAILING ADDRESS: STREET <br />CITY t STATE t'jv ZIP LlJ <br />OWNER PHONE: ^ Z/©� - z�*� <br />OWNER EMAIL: <br />CONTRACTOR NAME: <br />CONTRACTOR ADDRESS: STREET Pb <br />CITY �% STATE ZIP <br />CONTRACTOR PHONE: '%Z, 33 <br />CONTRACTOR EMAIL: <br />CONTRACTOR LIC. #(REQUIRED): . ` & CITY OF EVERETT BUSINESS LIC. #(REQUIRED): <br />_. .,._ . _.. _.,...._ w ... ...... . <br />PRIMARY CONTACT: 54OWNER ❑CONTRACTOR ❑OTHER (Please Specify) <br />CONTACT NAME: <br />J+i ' ' p, <br />CONTACT PHONE: <br />CONTACT EMAIL: <br />AGREEMENT: I nereby cemty mat I nave reaa ana exammea Mrs appllcauon ano Know me same ro oe rrue ano correct. fin pruwsiuns ul idws dnu vrmndncas yuv­ llllly ilia <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 1 <br />comply with the at Contractors Law 18.27 RCW and 296.200 WAC. City of Everett Official Use Only <br />PERMIT M <br />Owner/Authorized Agent Signature Date (Revised 111112019) Page 1-Application <br />