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0 <br />ELECTRICAL PERMIT APPI—PATION <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 />PR�dECY �1TE 1{diF®Rp®N <br />PROJECT ADDRESS: <br />PROJECT TYPE: ® NEW CONSTRUCTION <br />BUILDING USE: ® SeFRc/aq�®9 /T�OpWNH/�OUS <br />�is6ir :lf- LtICAL :99Q <br />CONTRACT PRICE OF WORK: $ <br />DESCRIBE SCOPE OF WORK: <br />v` <br />S ,`CVL (Y L.i� Ci%�C BUILDING AREA: sq ft <br />® ADDITION TENANT IMPROVMENT ® REMODEL <br />E DUPLEX ® ADU ® MULTI -FAMILY - # OF UNITS: COMMERCIAL <br />F WORK <br />ASSOCIATED BUILDING PERMIT # (if applicable): <br />THIS INSTALLATION INCLUDES THE FOLLOWING SCOPE: (SELECT ALL THAT APPLY) <br />LINE VOLTAGE WORK? M NO ® YES -Select Scope: ® Service ®Feeder [3 Circuits-#: ® Complete Re -wire <br />1 <br />LOW VOLTAGE WORK? ®NO 0 YES- # of Devices: <br />SELECT SCOPE (REQUIRED): <br />❑ 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 fg�r review of device locatio and ins I ation approval <br />Other (List All): J' <br />IS THIS PERMIT EDUCATION, INSTITUTIONAL, HEALTH AND/OR PERSONAL CARE FACILITIES NO DYES -- 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 ❑YES -See Below & Pg. 3 <br />El <br />ers cannot perform electrical work on buildings for rent, sale, or lease <br />Pursuant to RCW 19.28.261, property owners and leasehold <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 />CQhtT.AC7.lNORMAT(ON. `. <br />OWNER NAME TENANT BUSINESS NAME (If Commercial): t, Oir cc,� <br />OWNER MAILING ADDRESS: STREET <br />STATE ZIP <br />CITY <br />OWNER PHONE: OWNER EMAIL , ,.....- ,. - <br />CONTRACTOR NAME: <br />103 <br />CONTRACTOR ADDRESS STREET f/�C1 /I��i�G �Y�' f A r'--=--� <br />STATE ���� ZIP <br />CITY <br />CONTRACTOR PHONE: '• r CONTRACTOR EMAIL: <br />CONTRACTOR LIC. #(REQUIRED): CITY OF EVERETT BUSINESS LIC #(REQUIRED). <br />PRIMARY CONTACT: ❑ OWNER ❑ CONTRACTOR N OTHER (Please Specify) (� Ilnna..— <br />CONTACT NAME: CONTACT PHONE: <br />hCONTACT EMAIL: <br />AGREEMENT: 1 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 governing this <br />authority to violate or cancel the provisions of any other state or <br />type of work will be completed whether specified herein or not. The granting of a permit does not presume to give ion is <br />local law regulating construction or the performance of construction. That/ am authorized by the owner of this property to perform the work for which City of Everett pplc atl Use made and' <br />comply with the State Contractors Law 18.27 RCW and 296.200 WAC. PERMIT #: <br />Ow erl oriaed Age- gnat- Date % (Revised Page 1-Application <br />