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1 man <br /> • • <br /> uns ELECTRICAL PERMIT APPLIC TIO <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 /> PROJECT ADDRESS: ,jf,'` i. 1. 41`1 tZ° S% 5r BUILDING AREA: sq 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 8, DESCRIPTION.OF WORK <br /> CONTRACT PRICE OF WORK:$ (.0(. ""'--- ASSOCIATED BUILDING PERMIT#(if applicable): <br /> DESCRIBE SCOPE OF WORK: ha Z/U V CI,7.k.4,i 1 1,--- /9G <br /> THIS INSTALLATION INCLUDES THE FOLLOWING SCOPE: (SELECT ALL THAT APPLY) <br /> LINE VOLTAGE WORK? fl' YES Select Scope: ❑ Service ❑ Feeder .Circuits#: El Complete Re wire <br /> LOW VOLTAGE WORK? '' I-NO ❑YES-#of Devices: <br /> SELECT SCOPE(REQUIRED):, 51Lata- ❑ Intercom Cl Thermostat ❑Audio ❑ Secure Access ❑ Security System <br /> El 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: El 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: ENO 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: lotetjd- bj li/G/a;/-,d/, TEN1 ANT BUSINESS NAME(If Commercial): <br /> OWNER MAILING ADDRESS: STREET F>C)I [ 1 t 5% -5 <br /> CITY F. -Pc'` 1. STATE ZIP 9 g 2)3 <br /> OWNER PHONE: OWNER EMAIL: <br /> CONTRACTOR NAME: S!" l,E?.e,/fi__ L-L-C- <br /> CONTRACTOR ADDRESS: STREET C -! ( 7 \ 7 ? !J'Z Air:_- <br /> CITY V V 0,4" l S J I f -e STATE A ZIP CI J 2 7 0 <br /> CONTRACTOR PHONE:t{23— 767'7 6 y 7 CONTRACTOR EMAIL: OAS('P�lcc. e^tC.U�:- ED> 9 del I I. Cd'.� <br /> CONTRACTOR LIC.#(REQUIRED): tvtS�'f LG� 1 i, A CITY OF EVERETT BUSINESS LIC.#(REQUIf�tED): <br /> ., <br /> PRIMARY CONTACT: A WNER- ❑CONTRACTOR ❑OTHER(Please Specify) <br /> CONTACT AME• CONTACT PHONE: 02_5— 7(,0 6,i /7 <br /> /61��4. 5;41104 CONTACT EMAIL: S e L'-/C'E.i h' /G L LC C t'VGA' I I . CO.1 A, <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 an 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 co struction 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 St t Contractors Law 18.27 RCW and 296.200 WAC. City of Everett Official Use Only <br /> PERMIT#: <br /> E icto -i -o <br /> A, , NT-ir:„C. <br /> FOwner1Auttiorized Agent Signature Date (Revised 1/11/2019) Page 1-Application <br />