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0 0 <br /> 4Err ELECTRICAL PERMIT APPLICATION <br /> CITY OF EVERETT PERMIT SERVICES <br /> 3200 CEDAR STREET,EVERETT,WA 98201 <br /> (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: ?)p) `o \9 \ BUILDING AREA: sq ft <br /> PROJECT TYPE: ❑NEW CONSTRUCTION ❑ADDITION 121 TENANT IMPROVMENT ❑REMODEL <br /> BUILDING USE: ❑SFR ❑TOWNHOUSE 0 DUPLEX ❑ADU ❑MULTI-FAMILY-#OF UNITS: I7I COMMERCIAL <br /> ELECTRICAL APPLICATION:INFORMATION & DESCRIPTION OF WORK .\. <br /> CONTRACT PRICE OF WORK:$ 0' ASSOCIATED BUILDING PERMIT#(if applicable): , <br /> DESCRIBE SCOPE OF WORK: X VQ\IWAVN �� OC-\\(a C � P�1E�_\ �' (\ cif t 0 <br /> THIS INSTALLATION INCLUDES THE FOLLOWING SCOPE:(SELECT ALL THAT APPLY) <br /> LINE VOLTAGE WORK? NO ❑YES-Select Scope: ❑Service ❑Feeder ❑Circuits-#: ❑Complete Re-wire <br /> LOW VOLTAGE WORK? ❑NO DELXES-#of Devices: Z <br /> SELECT SCOPE(REQUIRED): 0 Data ❑Intercom ❑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 COMPLIANCE <br /> IS THIS PERMIT EDUCATION,INSTITUTIONAL,HEALTH AND/OR PERSONAL CARE FACILITIES: I, NO El 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: ONO OYES-See Below&Pg.3 <br /> ❑ Pursuant to RCW 19.28.261,property owners and leaseholders cannot perform electrical work on buil ' gs 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 ,. . • ttl <br /> OWNER NAME: TENANT BUSINESS NAME(If Commercial): j\L�J T11Ct 4'Q <br /> OWNER MAILING ADDRESS: STREET' ') )\) ` %C)C J'-. CIA) <br /> J <br /> Ii iCITY T)I'C d STATE N ZIP C,�F�/i <br /> OWNER PHONEkLX >, 1( ' \O '?, �r'OWNEREMAIL:��O\' QI A`���\�OO.h�11C.�\o1�o€?, �7( (- <br /> CONTRACTOR NAME: ��V,C'XACCVOt ' X( �;0(6 , 't Ufa ✓ �J <br /> CONTRACTOR ADDRESS: STREET I� ` AN,'' •"✓ <br /> CITY v <br /> 7 () STATE �I V ZIP \ <br /> � <br /> CONTRACTOR PHONE(70:0lQ ,3-73.-Vtp CONTRACTOR EMAIL 11(('t�Er)1 CJA�r1cy�W A D Y( Ckyl4C W-)rn• <br /> LIC.#REQUIRED:^ - CITY OF EVERETT BUSINESS LIC:#(REQUIRED):(` <br /> CONTRACTOR ( . )���Q���YT�D�,' ��c`"J/ <br /> PRIMARY CONTACT: ❑OWNER k1 CONTRACTOR 0 OTHER(Please Specify) <br /> CONTACT NAME: CONTACT PHONE: 4-1 — <br /> —\--)PiAW C-sNL )lA,hk 91 CONTACTEMAIL:A rw kik ��t(c( GrI�C��C ki�1:��Ci(1 L.Qm1 <br /> liGREEMENT:I hereby certify t at I"l° read and examined this application and know fh same to V trite d correct. AllAvisions of laws and ordinances govetning this <br /> whether specified herein or not. The granting of a permit does not presume giveauthority to violate or cancel the provisions of any other state or <br /> typea of worke lal be completed pwork for which application is made <br /> focal taw regulating construction or the performance of construction. That I am authorized by the owner of this property to perform the City of Everett Official Use Only and! <br /> comply with the State Contractors Law 18.27 RCW and 296.200 WAC. <br /> PERMIT#: <br /> E 210 - 1� <br /> Owner/Authorized gent nature Date (Revised 1/11/2019) Page 1-Application <br />