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<br /> Lai ELECTRICAL PERMIT APPLICATION
<br /> CITY OF EVERETT PERMIT SERVICES
<br /> EVERETT 3200 CEDAR STREET,EVER i I,WA 98201
<br /> wASRINOTON (P)425-257-8810 I FAX 425-257-8857 I(E)everetteps@everettwa.gov I wwweverettwa.gov/permits
<br /> ospociolit Jolocompg.i.a,..,, ArstrgwoRmAtrwokiwww:Awaii7a4p,71-Fi'07
<br /> PROJECT ADDRESS: '602- 2'r icke e va14 EVe,Ce*i-- BUILDINGAREA: sq ft
<br /> PROJECT TYPE: IdNEW CONSTRUCTION El ADDITION El TENANT IMPROVMENT REMODELN
<br /> BUILDING USE: SFR 0 TOWNHOUSE El DUPLEX El ADU ID MULTI-FAMILY-#OF UNITS: El COMMERCIAL
<br /> 4z:' C0/104,VPRIOXIMAisato..''100AWAION445:1):L.,:.t,.;:.,pr,.1,;ii.:?Lit i ,Ricr- ---a;:i'xic
<br /> CONTRACT PRICE OF WORK:$ 2-101) ASSOCIATED BUILDING PERMIT#(if applicable):
<br /> DESCRIBE SCOPE OF WORK: 2.00 , 1 IMO rAnn Cl1&4i6"e--
<br /> ,
<br /> THIS INSTALLATION INCLUDES THE FOLLOWING SCOPE: (SE CT ALL THAT APPLY)
<br /> LINE VOLTAGE WORK? 0 FIVES-Select Scope: Service El Feeder El Circuits-#: El Complete Re-wire
<br /> LOW VOLTAGE WORK? E1 NO El YES-#of Devices:
<br /> SELECT SCOPE(REQUIRED); 1:1 Data El Intercom 0 Thermostat 0 Audio 0 Secure Access El 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 /> El Other(List All):
<br /> zzial,:sm::::#040=Mr- ',1; ''':,: -.ODEOMPUANCE'37ASICZTA ' g:':':1-4'1'''';';', ' '''''-'! 'S
<br /> IS THIS PERMIT EDUCATION,INSTITUTIONAL,HEALTH AND/OR PERSONAL CARE FACILITIES: Li NO ij YES-See Below&Pg.2
<br /> El 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 OYES-See Below&Pg,3
<br /> El] Pursuant to ROW 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 /> W5larifT?::M77',;t;''''!'''X'1';'77:71IP,.'1CONTLANM.,, .:,....si,;,'11..!!4.,::A11,10:,iiii ; ' 17;7,iiiliPiiiiilitiNifleiV15.
<br /> OWNER NAME: It At 4 a q I C/C.-- MeiNi i rii TENANT BUSINESS NAME(If Commercial):
<br /> OWNER MAILING ADDRESS: STREET 02_ Ii5n 6\c .c. NO".-1
<br /> en eWvt4t STATE VIA 2 I PC/.9 213 1
<br /> OWNER PHONE: VI Ok. OWNER EMAIL:
<br /> CONTRACTOR NAME: ' 1Y1 Jrteuse E-t-e,Co-1&,
<br /> CONTRACTOR ADDRESS: STREET li 0 1‘mr lin bY. St-.
<br /> CITY Lake SteAr91/6 STATE v4 A ZIP(21(32, C))
<br /> i‘
<br /> CONTRACTOR PHONE:42.c.1(DO /2-)2,-0-b CONTRACTOR EMAIL: i NIX(4(Y\TV:50.... ry-0.:0
<br /> CONTRACTOR LIC.#(REQUIRED):i 14 A"\-0‘.A*C--1,,51‘62.-(5k33 CITY OF EVERETT BUSINESS LIC. (REOUIRED) ‘t %
<br /> PRIMARY CONTACT: OWNER DCONTRACTOR DOTHER(Please Specify)
<br /> CONTACT NAME: weo,Q,7, CONTACT PHONE: A26. 2)2.0 (71\ LA il
<br /> CONTACT EMAIL: .1troffjyry117 ,,, yy)ex., t . CPL.'1'If•N
<br /> AGREEMENT:I hereby certify that I have read and examined this application and know the same to be tru and correct, All provisions laws and ordinances governing this
<br /> type of work will be completed whether specified herein or not. The granting of a petmit does not presume to give authority to violate or cancel the provisions of any other state or
<br /> local law regulating construction or the perfo a of construction. That lam authorized by the owner of this property to perform the work for which application is made and)
<br /> comply with a State tract?tary 18.27 CW an 296.200 WAC, City of Everett Official Use Only
<br /> PERMIT#:
<br /> ) / 0 ifi Z-C)
<br /> i E 2,00( — o2_2_
<br /> Owned thorized Agent Signature Date (Revised111112019) Page 1-Application
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