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0 <br />ELECTRICAL PERMIT APPLICATION <br />EVERETT <br />wncuini r_rnu <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 SITEINPORMATIOU.; <br />a <br />PROJECT ADDRESS:'—? Q r <br />BUILDING AREA: sq ft <br />PROJECT TYPE: ❑ NEW CONSTRUCTION ❑ ADDITI N PITENANT IMPROVMENT ❑ REMODEL <br />BUILDING USE: ❑ SFR ❑ TOWNHOUSE ❑ DUPLEX ❑ ADU ❑ MULTI -FAMILY - # OF UNITS: 21ZDMMERCIAL <br />ELECTRICAL APPLICATION`'INFMJRMATION <br />_....,.. <br />8. DESCRfPT10N :OF WORK <br />CONTRACT PRICE OF WORK: $ <br />ASSOCIATED BUILDING PERMIT # (if applicable): <br />DESCRIBE SCOPE OF WORK: Z — <br />e-k` i <br />V <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 KYES- # 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 />ODE COMPLIANCE' <br />IS THIS PERMIT EDUCATION, INSTITUTIONAL, HEALTH AND/OR PERSONAL CARE FACILITIES: OEl YES -- See Below & Pg. 2 <br />❑ By checking this box, I am stating that I have read and understand all of WAC 296-46113-900, 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: 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 />TMFGT:;INFORMATION <br />OWNER NAME: TENANT BUSINESS NAME (If Commercial): <br />OWNER MAILING ADDRESS: STREET <br />CITY STATE ZIP <br />OWNER PHONE: <br />OWNER EMAIL: <br />CONTRACTOR NAME: <br />CONTRACTOR ADDRESS: STREET <br />n <br />CITY STATE ZIP <br />CONTRACTOR PHONE. Z <br />11 11 <br />CONTRACTOR EMAIL: \ ,W0, \ • C-O <br />CONTRACTOR LIC. #(REQUIRED): I K CITY OF EVERETT BUSINESS LIC. #(RE IRED): <br />.,. CON TRACTOR ❑OTHER (Please Specify) <br />PRIMARY CONTACT: ❑OWNER <br />CONTACT NAME: <br />CONTACT PHONE: <br />CONTACT EMAIL: <br />AGREEMENI: I hereby cemry that I have readLama examined this appucanon ana «now me same to be true anu cunew. <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 I <br />comply with the State Contractors Law 18.27 RCW and 296.200 WAC. City of Everett Official Use Only <br />PERMIT #: <br />;.2n.r/A t Agent Si ure Date (Revised 1/1112019) r Page 1-Application <br />