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0 •ION <br /> ELECTRICAL PERMIT APPLI <br /> CITY OF EVERETT PERMIT SERVICES <br /> ✓ 3200 CEDAR STREET,EVERETT,WA 98201 <br /> NV J 7 i <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 /> • , l - � <br /> PROJECT ADDRESS: 2-ZZZ- Z<): �r,4,j. GJCt'"r, We i�-}'Z'liBUILDING AREA: s9 ft <br /> PROJECT TYPE: ❑NEW CONSTRUCTION ❑ADDITION ❑TENANT IMPROVMENT ❑ REMODEL <br /> BUILDING USE: ❑SFR ❑TOWNHOUSE ❑DUPLEX ❑ADU ❑MULTI-FAMILY-#OF UNITS: ❑ COMMERCIAL <br /> ELECTRICAL APPLICATION INFORMATION & DESCRIPTION OF WORK <br /> CONTRACT PRICE OF WORK: $ i, 2.00 dr) (ASSOCIATED BUILDING PERMIT#(if applicable): <br /> DESCRIBE SCOPE OF WORK: J< ( ?LA eC_ (-----xi 3-7 ' iv., C4tp l 7'57(�) /. xrs7-;Ail <br /> W,if-S <f-- CoAld1 7(A/ <br /> THIS INSTALLATION INCLUDES THE FOLLOWING SCOPE: (SELECT ALL THAT APPLY) <br /> LINE VOLTAGE WORK? ❑NO EYES-Select Scope: ❑ Service ❑Feeder ®Circuits-#:3 ❑Complete Re-wire <br /> LOW VOLTAGE WORK? ❑NO EYES-#of Devices: I <br /> SELECT SCOPE(REQUIRED): <br /> ®Data 0 Intercom 0 Thermostat ❑Audio ❑Secure Access 0 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 /> CODE COMPLIANCE <br /> IS THIS PERMIT EDUCATION,INSTITUTIONAL,HEALTH AND/OR PERSONAL CARE FACILITIES: E3 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-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:ElNO OYES-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: ] ram. C. C-b r O t'l6 4- TENANT BUSINESS NAME(If Commercial):Qj1-� Y114 A T v c.. <br /> OWNER MAILING ADDRESS: smEET OS S A?P ar/ / ZIP Q p LO r <br /> CfTY G t 1 e , t'" STATE (AAA� /0 <br /> OWNER PHONE: 2-06 6 7 a - 5SUCIOWNER EMAIL: I RI4CVI C.)(5 D0U 4 L. L H 6.0444►/SO41 Coon <br /> CONTRACTOR NAME: t , l A S(<.f L— of✓f i'vh e ` �1 1M 4 <br /> rw ol. S , 7 <br /> CONTRACTOR ADDRESS: STREET ( S j S'' , <br /> C7TY S C 4,�� STATE jf� <br /> CONTRACTOR PHONE:2O6763 Ts-67 (CONTRACTOR tw)� ZiP g��EMAIL: A-t 1i i)D G=2-0 /IA's( i/ec, C e" u <br /> CONTRACTOR LIC.#(REQUIRED): mAS CQCC` 57C b jCITY OF EVERETT BUSINESS LIC.#(REQUIRED): 0 `1 r°I$'t <br /> PRIMARY CONTACT: ❑OWNER 0 CONTRACTOR nrOTHER(Please Specify) il'G i-, , t i fi'l <br /> CONTACT NAME: CONTACT PHONE: 3 (}.- 870— 463 1 <br /> E'G <br /> 3 L ?}cPli J C CONTACT EMAIL: J G L. <br /> —jut ,0 G►2,@. i &sc,14 . co ).% <br /> ,that <br /> :I ,`W hereby certify that 1 have read and examined this application and know the same to be true and correct. All provisions of laws and ordinances governther ing thise <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 provisions6of any o he s atl or <br /> local law regulating construction or the performance of construction. That I am authorized by the owner of this property to perform the wor rk for <br /> whrctt applcati n is s Only <br /> comply with the State Contractors Law 18.27 RCW and 295.200 WAC. CltPERMIT#: <br /> IL `' L 2/ y// (Revised 1/11/2019) Page 1-Application <br /> Owner/Authorized Agent Signatur Date <br />