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0 • <br /> mom <br /> irmi ELECTRICAL PERMIT APPLICATION <br /> EVERETT CITY OF EVERETT PERMIT SERVICES <br /> 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 /> PROJECTaSITE INFORMATION, <br /> r� 1,,, ,/ fro <br /> PROJECT ADDRESS: P 2 VVCXQ Aver U BUILDING AREA: sq ft <br /> PROJECT TYPE: ❑ NEW CONSTRUCTION ❑ADDITION 1,8 TENANT IMPROVMENT ❑ REMODEL <br /> BUILDING USE: El SFR ❑TOWNHOUSE El DUPLEX El ADU ❑ MULTI-FAMILY-#OF UNITS: ❑ COMMERCIAL <br /> ELECTRICAL APPLICATION INFORMATION & DESCRIPTION OF WORK <br /> CONTRACT PRICE OF WORK:$ q I D •OD ASSOCIATED BUILDING PERMIT#(if applicable): gyp <br /> DESCRIBE SCOPE OF WORK: V.ec )1 sog MU COM STSkm Vv`r lr <br /> THIS INSTALLATION INCLUDES THE FOLLOWING SCOPE: (SELECT ALL THAT APPLY) <br /> LINE VOLTAGE WORK? gNO ❑YES-Select Scope: ❑ Service El Feeder ❑ Circuits-#: ❑Complete Re-wire <br /> LOW VOLTAGE WORK? El NO 1YES-#of Devices: <br /> SELECT SCOPE(REQUIRED): ❑ Data li.Intercom ❑Thermostat ❑Audio El 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 /> El Other(List All): <br /> CODE COMPLIANCE <br /> IS THIS PERMIT EDUCATION,INSTITUTIONAL,HEALTH AND/OR PERSONAL CARE FACILITIES: ❑ NO ❑YES--See Below&Pg.2 <br /> nI 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: ONO 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: Eve,kii C ip 'C //�� TENANT BUSINESS NAME(If Commercial): <br /> 3`'OWNER MAILING ADDRESS: STREET 101 ki o\it role <br /> CITY 't STATE Wei. <br /> ZIP Ci S2D l <br /> OWNER PHONE: 1.42 -3``i1.-- 3 tcs2. OWNER EMAIL: <br /> CONTRACTOR NAME: el, va -01 ax) SC. U - y eUpkt. 'I 1S <br /> CONTRACTOR ADDRESS: STREET r LJ. \ t J • <br /> CITY ..a.:-I STATE L l ZIP qgl'u <br /> CONTRACTOR PHONE: CONTRAC/TOOR EMAIL: <br /> CONTRACTOR LIC.#(REQUIRED): arty-)5�2 A �}5 CITY OF EVERETT BUSINESS LIC.#(REQUIRED):v.S 3 <br /> PRIMARY CONTACT: DOWNER CONTRACTOR DOTHER(Please Specify) L <br /> CONTACT NAME: ,, .' CONTACT PHONE: 24J�—(p 2 Z- lL1 L_1 s ex-\ 2,-n <br /> CII21ixt� h1 CONTACT EMAIL: e,fiShzir (9.. „; j all ge(,(,(� •(OWt <br /> AGREEMENT:I hereby certify that I have read and examined this application and know the same to be true and correct. l 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 /> bq Diq Io) E 1,00(6- L <br /> Owner! thorized Agent Si ature Date (Revised 1/11/2019) Page 1-Application <br />