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4 <br /> E ECTRICAL PERMIT APPLICATION <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: /`- L54- L„..34. 9g. 1 T )5 BUILDING AREA: 1C_=C5 sgft <br /> PROJECT TYPE: ❑ NEW CONSTRUCTION El ADDITION El TENANT IMPROVMENT ❑ REMODEL <br /> BUILDING USE: El SFR ❑TOWNHOUSE ❑ DUPLEX El ADU El MULTI-FAMILY-#OF UNITS: ❑ COMMERCIAL <br /> ELECTRICAL APPLICATION INFORMATION & DESCRIPTION OF.WORK , <br /> CONTRACT PRICE OF WORK:$ ASSOCIATED BUILDING PERMIT#(if applicable): <br /> DESCRIBE SCOPE OF WORK: Ni-e-v" �y ik t_kic <br /> OtIbLeA ,d.Q v - SOU tiIgU�.P� <br /> THIS INSTALLATION INCLUDES THE FOLLOWING SCOPE: (SELECT ALL THAT APPLY) <br /> LINE VOLTAGE WORK? El NO ,I YES-Select Scope:XService ❑ Feeder ❑Circuits-#: El Complete Re-wire <br /> LOW VOLTAGE WORK? El NO ❑YES-#of Devices: <br /> SELECT SCOPE(REQUIRED): ❑ Data El Intercom El 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 for review of device location and installation approval. <br /> ❑Other(List All): <br /> - CODE <br /> IS THIS PERMIT EDUCATION,INSTITUTIONAL,HEALTH AND/OR PERSONAL�CA �REFACILITIES: t,NO CI YES—See Below&Pg.2 <br /> I I 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: 01VO DYES-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: e.. TENANT BUSINESS NAME(If Commercial): <br /> OWNER MAILING ADDRESS: STREET -3 UY;�L (&L ock c ; �. r <br /> cmy �-h S\ STATE ( J r!, ZIP of V i <br /> OWNER PHONE: •!•Yt 4070 ---141.3OWNER EMAIL. I.L2K�LuS �i�`"`y.... `Q t.. .. <br /> CONTRACTOR NAME: <br /> CONTRACTOR ADDRESS: STREET 11/2,1 4-v-t O ES A. <br /> c7 <br /> CITY Ti 1._ STATE t.-4- [ /i C( S ZIP G <br /> CONTRACTOR PHONE: '25 j'36—?UQ(,o CONTRACTOR EMAIL: I c e. 1 7,1 ^� v—•Q `�C �' t `�`u <br /> CONTRACTOR LIC.#(REQUIRED): t lD23QK CITY OF EVERETT BUSINESS LIC.#(REQUIRED): <br /> PRIMARY CONTACT: DOWNER rgic,ONTRACTOR ❑OTHER(Please Specify) <br /> CONTACT NAME: S� CONTACT PHONE: LI d- '30— ?C c-, <br /> CONTACT EMAIL: ( e, et-w '2-�tL E+�� C - .+" <br /> AGREEMENT:I 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 /> 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 construction 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 State Contractors Law 18.27 RCW and 296.200 WAC. City of Everett Official Use Only <br /> PERMIT#: <br /> O r/ on ent Signature Date (Revised 1/11/2019) Page 1-Application <br /> 1. <br />