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• 0 <br /> ,�® ELECTRICAL PERMIT APPLICATION <br /> CITY OF EVERETT PERMIT SERVICES <br /> 3200 CEDAR STREET,EVERETT,WA 98201 <br /> (P)425-257-8810 I FAX 425-257-8857 I(E)everetteps@everettwa.gov I www.everettwa.gov/permits <br /> .. - PROJECT SITE INFORMATION <br /> PROJECT ADDRESS: LQ2,Ol i ,X-1`((I T_.-. ` /3 T \t-%\ BUILDING AREA: (k I(✓ L) sq ft <br /> PROJECT TYPE: 0 NEW CONSTRUCTION pi ADDITION 0 TENANT IMPROVMENT 0 REMODEL <br /> BUILDING USE: 0 SFR 0 TOWNHOUSE 0 DUPLEX 0 ADU 0 MULTI-FAMILY-#OF UNITS: 0 COMMERCIAL <br /> • ELECTRICAL APPLICATION INFORMATION 8 DESCRIPTION OF WORK <br /> ✓~,\�,\V ASSOCIATED BUILDING PERMIT#(if <br /> CONTRACT PRICE OF WORK:$ V ." applicable): <br /> �N <br /> DESCRIBE SCOPE OF WORK: \A>(, U EAC 'c •>.�°:-.): u6k (CO C f <br /> THIS INSTALLATION INCLUDES THE FOLLOWING SCOPE: (SELECT ALL THAT APPLY) <br /> LINE VOLTAGE WORK? 0 NO ®YES-Select Scope: 0 Service 0 Feeder 0 Circuits-#: ®Complete Re-wire <br /> LOW VOLTAGE WORK? 0 NO a YES-#of Devices: '' <br /> SELECT SCOPE(REQUIRED): ❑ Data ii Intercom 0 Thermostat 0 Audio 0 Secure Access 0 Security System <br /> 0 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: 1J NO 0 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 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: TENANT BUSINESS NAME(If Commercial): t-e,CA <br /> CIIA <br /> OWNER MAILING ADDRESS: STREET 03Cf) a' {6 L ° <br /> CITY - � `,� - i STATE k1�A zip '✓/'sk�` ��-`� <br /> CITY ) <br /> OWNER OWNER PHONE: OWNER EMAIL: .. .. <br /> CONTRACTOR NAME: ;til- (wj, 6.,.A(Dl4'\,, t`;u✓(A N, s\a ',i "t"A;'"°-=' <br /> CONTRACTOR ADDRESS: STREET l--14. 0 ') - <br /> CITY ). ki STATE ZIP CA, 1, <br /> CONTRACTOR PHONEMA "1�- I9--�V CONTRACTOR EMAIL: <br /> CONTRACTOR LIC.#(REQUIRED) ��-' ), 2- -Gf` % CITY OF EVERETT BUSINESS LIC.#(REQUIRED):tj,,,P 7j-k-''� <br /> PRIMARY CONTACT: ❑OWNER (CONTRACTOR 0 OTHER(Please Specify) <br /> CONTACT NAME: vl ( �i1 CONTACT PHONE:` 'vc ) 1(6— c11k("�Q <br /> AA YI�L `' `�V ��YN CONTACT EMAIL: �'l�tU� UI C',� Yt U.0�1�3� <1' L i'� C (,,l'f\ <br /> AGREEMENT:I hereby certify at I hate read and examined this application and know the same to a trut=and correct. Ali 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 Contractors Law 18.27 RCW and 296.200 WAC. City of Everett Official Use Only <br /> PERMIT#: <br /> Aner/Authorized A ant Si ature Date (Revised 1/11/2019) Page 1-Application <br />