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111 MIN <br /> I <br /> ELECTRICAL PERMIT APPLICATION <br /> CITY OF EVERETT PERMIT SERVICES <br /> EVERETT 3200 CEDAR STREET,EVERETT,WA 98201 <br /> WASHINGTON (P)425-257-8810 I FAX 425-257-8857 I(E)everetteps@everettwa.gov I www.everettwa.gov/permit <br /> PROJECT SITE INFORMATION " ' <br /> PROJECT ADDRESS:,j �;; BUILDING AREA: tl,' O03 sq ft <br /> PROJECT TYPE: CI NEW NEW CONSTRUCTION ADDITION ❑TENANT IMPROVMENT REMODEL <br /> BUILDING USE: SFR ❑ TOWNHOUSE ❑ DUPLEX ❑ADU ❑ MULTI-FAMILY-#OF UNITS: ❑ COMMERCIAL <br /> ELECTRICAL APPLICATION INFORMATION & DESCRIP'I QN OF WORN <br /> CONTRACT PRICE OF WORK:$ PO(O ASSOCIATED BUILDING PERMIT#(if applicable): ` ,, <br /> DESCRIBE SCOPE OF WORK: �Jerk�Yi � J Ut•,�( �i vUCIS Cr 1s t C, v <br /> A.e) C{;34, fikki (NIA- err ) <br /> rr <br /> ?-LE <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 ❑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 /> E Other(List All): <br /> CODE COMPLIANCE' <br /> IS THIS PERMIT EDUCATION, INSTITUTIONAL,HEALTH AND/OR PERSONAL CARE FACILITIES: NO ❑YES--See Below&Pg.2 <br /> By checking this box, I am stating that I have read and understand all of WAC 296-46B-90 ,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: 7NO EYES-See Below&Pg.3 <br /> Pursuant to RCW 19.28.261, property owners and leaseholders cannot perform electrical work on b ildings 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: •;n; ,iUJ,NA,}-_S TENANT BUSINESS NAME(If Commercial): <br /> OWNER MAILING ADDRESS: STREET .i Z Zy 3� r 5 <br /> CITY C,li�1,/-( .i�I �( 3.0• STATE ZIP <br /> ( <br /> OWNER PHONE:"Z) L &2 . OWNER EMAIL: Sk ' c;I\ R r ) <br /> CONTRACTOR NAME: k-k..0 N Ie.cL c (LILL <br /> CONTRACTOR ADDRESS: STREET 311(j J 1 l L u I " 7� JIB <br /> CITY Cyr kr•I it; - I STATE LV�t./ ZIP 2�6_ <br /> 1 <br /> CONTRACTOR PHONE:t,� r-1,3 Li:2L2 CONTRACTOR EMAIL: v:IM"Q p(4 _Q e,fft'C e ,E�s-C ic'Ovtn&ti t .-co <br /> CONTRACTOR LIC #(REQUIRED) �-1 vm,�Qps Z ICITY OF EVERE T BUSINESS LIC.#(REQUIRED): <br /> PRIMARY CONTACT: DOWNER ZCONTRACTOR ❑OTHER(Please Specify) <br /> CONTACT NAME: CONTACT PHONE: 4 , 3(i W 2-2- <br /> \, r <br /> CONTACT EMAIL: �;�vrL N e I P ct..„, /� 3^' ,L�� <br /> AGR MENT:I hereby certify that I have read and examined this application and know the same to be true and correct. All provfsi ns of laws and ordinances governing this <br /> type of work will be corn leted 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 r ating constr Lion 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 I <br /> comp with the State Contr ctors Law 18.27 RCW and 296.200 WAC. City of Everett Official Use Only <br /> PERMIT#: <br /> E 1q 0R - eC) 0 <br /> r (Revised 1/11/2019) Page 1-Application <br /> Owner/Au' orized Agent Signature Date <br />