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0 <br />17-1 <br />ELECTRICAL PERMIT APPLICATION <br />CITY OF EVERETT PERMIT SERVICES <br />3200 CEDAR STREET, EVERETT, WA 98201 <br />7p1 425-257-AR1n I FAX 425-2.57-8857 1 (E) everettei)S(0)everettwa.gov I www.everettwa.gov/permits <br />PROJECT SITEINFORMATION:' <br />PROJECT ADDRESS: t, ZZ (/ <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 & DESORIPTION'OF WORK <br />CONTRACT PRICE OF WORK: $ © <br />ASSOCIATED BUILDING PERMIT # (if applicable): —� <br />DESCRIBE SCOPE OF WORK: N Q,W W 1 MAI(r 2100 f) V) U_ --ihelg-M D 5 • T <br />THIS INSTALLATION INCLUDES THE FOLLOWING SCOPE: (SELECT ALL THAT APPLY) <br />LINE VOLTAGE WORK? ❑ NO qYES - Select Scope: Service ❑ Feeder ❑ Circuits-#: ❑ Complete Re -wire <br />LOW VOLTAGE WORK? ❑ NO P YES- # of Devices: k <br />SELECT SCOPE (REQUIRED). ❑ Data ❑ Intercom 53 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 296-4613-900, 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: EINO OYES -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: TENANT BUSINESS NAME If Commercial): <br />OWNER MAILING ADDRESS: STREET <br />CITY STATE ZIP <br />OWNER PHONE: OWNER EMAIL: <br />CONTRACTOR NAME VA f IF l� C V21 C- A/C - <br />`) <br />CONTRACTOR ADDRESS: STREET 0 A4l N 1_ <br />� /n /f� ��-Ft_ <br />CITY 1/V E'I_''�•' I � STATE ZIP <br />/-� <br />CONTRACTOR PHONE: �U' Z �� CONTRACTOR EMAIL: U%QC -tYYZI �J V C� <br />CONTRACTOR LIC. #(REQUIRED): PG1�F O CITY OF EVERETT BUSINESS LIC #(REQUIRED): <br />PRIMARY CONTACT: ❑ OWNER PKCONTRACTOR ❑ OTHER (Please Specify) <br />CONTACT NAME: <br />V r (N I efi g%C.� <br />_ . . „_._ <br />CONTACT PHONE: `S(1) us- <br />^ <br />CONTACT EMAIL: VH F—L-EC_7 P—/ C �i/ <br />_ _ _ •:__.:__ __� ._...., s,........,., a- k- f7— 7 7 —7-77 an nr Q,nns of laws and nrdinances OOveminp this <br />AGKLLMLN i s 7 nereoy cemry rndr 7 nave 7Cau auu c ouunau � _ -pt ^­.•,.„ .^. -- _ •- -_ -. _ _ _- <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 I am authorized by the owner of this property to perform the work for which application is made and / <br />comply with the Sta}� Contractors Law 18.27 RCW and 296.200 WAC. Cityof Everett Official Use Only <br />/' PERMIT #: <br />1_1"�_ I E ��oL� - V�(9 <br />Owner/Aut rized Agent Signature Date (Revised 1/1112019) Page 1-Application <br />