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Oct 22 19 08:52a Bob Jack 15096746777 <br />96746777 p.2 <br />ELECTRICAL PERMIT APPLICATION <br />CITY OF EVERETT PERMIT SERVICES <br />3200 CEDAR STREET, EVERETT, WA 98201 <br />(P) 425-257-BB10 I FAX 425-257-8857 1 (E) everetteps( vere%va.gov I www.evereitwa.govJpermits <br />.tee Asae <br />=- ..• <br />• _ - .. <br />- .. •- <br />-: _ '-.,.. `..: <br />y � <br />BUILDING AREA: sy ft <br />PROJECT ADDRESS: I i <br />PROJECT TYPE: ® NEW CONSTRUCTION 1TION PROVMENT ® REMODEL <br />®SFR TOWN SE ®D\JPLEX ®ADtI MULTI -FAMILY # OF UNITS OMMERCIAL <br />BUILDING USE <br />Al i'@.�C:ll�FDitM�1'1PION 8�;0�S t1PTOGNW711 <br />ASSOCIATED BUILDING PERMIT !1(if applicable): <br />CONTRACT PRICE OF WORK: $ a' <br />DESCRIBE SCOPE OF NUORK,1 r <br />j f <br />INCLUDES THE FOLLOWING SCOPE: (SELECT ALL THAT APPLY) <br />THIS INSTALLATION <br />®iV0 S Select Scope: ®Service ® Feeder ® Circuits-#: ®Complete Re -wire <br />LINE VOLTAGE WORK? - <br />LOW VOLTAGE WORK? NO YES-# of Devices: <br />SELECT SCOPE (REQUIRED): ata Intercom 13 7 e oslat ❑ Audio ' E3 Secure Access E3Security System <br />Installations under this permit only include electrical wiring rough -in of the system. An additional <br />Fire Alarm - <br />Fire Alarm Permit is required for review of device location and installation approval. <br />® Other (List All) _ <br />GPlVtPIiENGE <br />IS THIS PERMIT EDUCATION, INSTITUTIONAL, HEALTH ANDIOR PERSONAL CARE FACILITIES NO YES See Below & Pg. 2 <br />WAC 236.4ii6-9D0, s lected the specific reason on page 2 <br />By checking this box, I am stating that 1 have read and understand all of <br />ElAND Plan Review is NOT required because I meet all of the following sub sections that do not <br />of this application (see next page), <br />See Page 2 require Plan Revie.v. <br />YES See Befow & Pg, 3 <br />WORK AS THE CONTRACTOR WITHOUT ELECTRICAL LICENSURE: ts, <br />ARE YOU AN OWNER PERFORMING <br />and leaseholders cannot perform electrical work or' b it for rent, sale, or lease <br />® Pursuant to RCW 19.28.261, property owners <br />the electrical licensing and certification, or exemption. By checking this box, I am stating that I haVe Ebmpleted and <br />without proper <br />signed the AFFIDAVIT on page 3 of this application to receive an exemption from this Iicensrnglcertlf requirement - <br />See Rage:3 <br />s •�O.NTAfT=1NEQRMA�IEIt�_, , - � -- - <br />; <br />TENANT BUSINESS NAME if Commercial : < <br />OWNER NAME: <br />OWNER MAILING ADDRESS: STREET k C <br />' STATE u 1! <br />CrrY <br />OWNER PHONE: OWNER EMAIL: _ .... . -... __. . <br />CONTRACTOR NAME: - <br />CONTRACTOR ADDRESS: STREET <br />srnr ZIP <br />CONTRACTOR PHONE: CONTRACTOR EMAIL: <br />CONTRACTOR LIC, #(REQUIRED): CITY OF EVERETT BUSINESS LIC. #'REQUIRED): <br />PRIMARY CONTACT: ❑ OWNER CAONTRACTOR D OTHER (Please Specify) <br />CONTACT NAME' <br />CONTACT PHONE:lye <br />CONTACT EMAIL: •� <br />- .,,,.. nn .,.,,,,:���,s nrraws and ordinances aovemin+� this <br />� i <br />typo of workyrrlr'6e a <br />local law regulating rA <br />comply lvIr me Stale <br />I have read and examined this applcatlon ano xno,v gnu Jd"l- IV w& „.. �1•� ��•�- -' - - <br />harspecifedherein Drool. The granting of a permit does not pmsvme to give authority to vioraie or cancel The prow tons o! any other state or <br />the perrarmance or construction. That i am authorizedby the owneror this propoity to perform the Co o! r %-hk eppf j al Is ma <br />Onde and f <br />.aw 16.27 pow and 296. 200 WAC. <br />PERMIT #: <br />Cf 2- Z E <br />nara (Revised fI11/2099) Page 1-Application <br />