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4111 <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 FAX 425-257-8857 I(E)everetteps@everettwa.gov I www.everettwa.gov/permits <br /> PROJECT'SITE lNFORMATI N <br /> PROJECT ADDRESS: 1,520 Gv �f/moo ?Z aI �-(b R BUILDING AREA: sq ft <br /> PROJECT TYPE: ❑NEW CONSTRUCTION ❑ADDITION ❑TENANT IMPROVMENT ® REMODEL <br /> BUILDING USE: ❑SFR El TOWNHOUSE ❑ DUPLEX ❑ADU ® MULTI-FAMILY-#OF UNITS: / ❑COMMERCIAL <br /> ELECTRICAL APPLICATION;INFORMATION <br /> CONTRACT PRICE OF WORK:$ 300 ASSOCIATED BUILDING PERMIT#(if applicable): 3 / c may-cc t/ <br /> DESCRIBE SCOPE OF WORK: ,2p/qce, z t <br /> THIS INSTALLATION INCLUDES THE FOLLOWING SCOPE: (SELECT ALL THAT APPLY) <br /> LINE VOLTAGE WORK? ❑ NO ❑YES-Select Scope:❑Service ❑ Feeder 2 Circuits-#: / ❑Complete Re-wire <br /> LOW VOLTAGE WORK? ❑ NO ❑YES-#of Devices: <br /> SELECT SCOPE(REQUIRED): ❑Data Cl Intercom ❑Thermostat ❑Audio ❑Secure Access El 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 /> IS THIS PERMIT EDUCATION,INSTITUTIONAL,HEALTH AND/OR PERSONAL CARE FACILITIES: g 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: NO EYES-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:&f elen t q w. /1?}i TENANT BUSINESS NAME(If Commercial): <br /> OWNER MAILING ADDRESS: STREET L/ lei C54lC Vfr,9 sf 7 o <br /> CITY STATE 7 -- ZIP 7g?75 <br /> OWNER PHONE: OWNER EMAIL: <br /> CONTRACTOR NAME: I;4 I(S e/�Lc�c <br /> CONTRACTOR ADDRESS: STREET ?p /3 O)e- 4776 <br /> CITY`i.7..- r1/d STATE Lr:/t? ZIP 98 z c/ <br /> CONTRACTOR PHONE: CONTRACTOR EMAIL:CONTRACTOR LIC.#(REQUIRED): CI. r�� C L. DJci Al CITY OF EVERETT BUSINESS LIC.#(REQUIRED): 5350.8 <br /> PRIMARY CONTACT: DOWNER [jCONTRACTOR ❑OTHER(Please Specify) <br /> CONTACT NAME: CONTACT PHONE: <br /> CONTACT EMAIL: <br /> AGREEMENT:I hereby certify that I have read and examined this application and know the same to be true and correct. All provisions of laws and ordinances governing this <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 I <br /> comply with the State Co actors Law 18.27 RCW and 296.200 WAG. City of Everett Official Use Only <br /> PERMIT#: <br /> 7-11-2019 E no R � 2 <br /> OwnerlAuthorized Agent Signature <br /> Date (Revised 1/11/2019) Page 1-Application <br />