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<br /> Lill 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/permits
<br /> PROJECT SITE INFORMATION
<br /> I + J S�%c- sq ft
<br /> PROJECT ADDRESS: �G6� W . Mn-7?-ice �f t��r�J ?/� BUILDING AREA:
<br /> PROJECT TYPE: ❑ NEW CONSTRUCTION ❑ADDITION ❑TENANT IMPROVMENT ❑ REMODEL
<br /> BUILDING USE: ❑SFR El TOWNHOUSE UPL ❑ADU ❑ MULTI-FAMILY-#OF UNITS: 1 COMMERCIAL
<br /> ELECTRICAL APP ` ATJON I FORMATION A DESCRIPTION OF WORK
<br /> CONTRACT PRICE OF WORK:$ - y 366,0 ASSOCIATED BUILDING PERMIT#(if applicable):
<br /> DESCRIBE SCOPE OF WORK: ,f,,(,. I'-i'T,={-�-i % S `1-c cc.Y,' l /5 ( ` A-//M✓Ii iS--(-€ -- E C
<br /> 1.,' t-, ff-'-e. 5
<br /> k ..,,. ..r-wus,—-6- \pc,)--Nre-k.,
<br /> 7._r_
<br /> THIS INSTALLATION INCLUDES THE LLOWIN SCOPE: (S LL THAT APPLY)
<br /> 1-1
<br /> LINE VOLTAGE WORK? ❑ El YES Select Scop Servic ❑
<br /> � Feeder El Circuits#: ElComplete Re-wire
<br /> r
<br /> LOW VOLTAGE WORK? El N El YE #of Devices ?
<br /> SELECT SCOPE(REQUIRED): El D to P./Intercom Thermost El Audio ❑ Secure Access El Security System
<br /> tIFire arm- Installations under ' 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 /> El Other(List All):
<br /> CODE COMPLIANCE
<br /> IS THIS PERMIT EDUCATION, INSTITUTIONAL, HEALTH AND/OR PERSONAL CARE FACILITIES: El 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:ONO 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: ? , - , r-' - 1 Cs,, et i � TENANT BUSINESS NAME(If Commercial): yk-t ;l,,(t 6-Aulik.6,
<br /> OWNER MAILING ADDRESS: STREET j 7ce) Lti , Mrtx.<i✓,` v 1 L`i^_. __.t . �}
<br /> CITY l,'CrJ1 IA.—,ASTATE � ZIP —1 0,) ' 1
<br /> OWNER PHONE: OWNER EMAIL:
<br /> CONTRACTOR NAME: P > ( ' i 5 -61-1 S I r✓+ q j2R f,dA)
<br /> CONTRACTOR ADDRESS: STREET j 9//3(O tit- (A,(_-c-,L ,Ok t- y " • /6c q p
<br /> cry F f(J.4-LI c t( STATE t/L'11 ZIP CC'C ( I
<br /> CONTRACTOR PHONE: 9 Z C L12-c( CONTRACTOR EMAIL: (i2;s<A 6) QS /ti"fc--_,R ¢-F -con-1
<br /> CONTRACTOR LIC.#(REQUIRED): 0 IL-4 S" 1 /� 12 S G CITY OF EVERETT BUSINESS LIC.#(REQUIRED) tf6. I c 3
<br /> PRIMARY CONTACT: ❑OWNER ,CONTRACTOR ❑OTHER(Please Specify)
<br /> CONTACT NAME: CONTACT PHONE: ' .. . ,02) (.(Z 6
<br /> -\,&c.S .2A 6 C-I-'t - CONTACT EMAIL: y, (
<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 Contractors Law 18.27 RCW and 296.200 WAC. City of Everett Official Use Only
<br /> PERMIT#:
<br /> Ed( /` 1/ --- 13, z6 E c°2 -<< 2---
<br /> Owner/Authorized Agentg Signature Date (Revised 1/11/2019) Page 1-Application
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