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• • <br /> ELECTRICAL PERMIT s PPLICATI•N <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 /> =_ '. ` PRQJEC`I`}�ITE;I�IIFORiI�A`fl®� , <br /> qL�! (BUILDING AREA: sq ft <br /> PROJECT ADDRESS: 21O - 6y y ei <br /> PROJECT TYPE: ®NEW CONSTRUCTION ®ADDITION 0 TENANT IMPROVMENT ® REMODEL <br /> BUILDING USE: 0 SFR 0 TOWNHOUSE DUPLEX E3 ADU 0 MULTI-FAMILY #OF UNITS: 21 COMMERCIAL <br /> ELECTRICAL APPLaICATIO :INFORMATIO D .. ESCRIPTION.OP WOR <br /> CONTRACT PRICE OF WORK:$ �G� (ASSOCIATED BUILDING PERMIT#(if applicable): <br /> DESCRIBE SCOPE OF WORK: �/ <br /> /4 cLt:c 1�T� &x 1 T `J�C�n1S %� L 080/ <br /> THIS INSTALLATION INCLUDES THE FOLLOWING SCOPE: (SELECT ALL THAT APPLY) <br /> LINE VOLTAGE WORK? NO ®YES-Select Scope: E3 Service 0 Feeder IM Circuits-#: ( 0 Complete Re-wire <br /> LOW VOLTAGE WORK? 1 NO ®YES-#of Devices: <br /> SELECT SCOPE(REQUIRED): <br /> ® Data ❑ Intercom 0 Thermostat 0 Audio 0 Secure Access 0 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 /> CI Other(List All): <br /> CODE;COMP(IANC1! :` <br /> IS THIS PERMIT EDUCATION,INSTITUTIONAL,HEALTH AND/OR PERSONAL CARE FACILITIES: p NO 0 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.ARE YOU AN OWNER PERFORMING WORK AS THE CONTRACTOR WITHOUT ELECTRICAL LICENSURE: WINO NO ®YES-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 IINFORMATION, , <br /> OWNER NAME: 6/:v"Tz 4l— 1«C E7h TENANT BUSINESS NAME(If Commercial): <br /> OWNER MAILING ADDRESS: STREET <br /> STATE ZIP <br /> CITY <br /> OWNER PHONE: -425 ZSZ- (OWNER EMAIL <br /> CONTRACTOR NAME: G Z TP -a.go- I G "Ai& <br /> CONTRACTOR ADDRESS: STREET f 2 &c- Zc1 CSC c���3 <br /> CITY �j1I STATE l�L'V ZIP <br /> CONTRACTOR EMAIL: , �)'("a✓i r f��/e.t-+� )c� G�I-- � <br /> CONTRACTOR PHONE: `�Z1✓ 3a /St I v <br /> CONTRACTOR LIC.#(REQUIRED) Nu/1 (CITY OF EVERETT BUSINESS LIC #(REQUIRED) <br /> PRIMARY CONTACT: ❑OWNER , CONTRACTOR 0 OTHER(Please Specify) 01 <br /> CONTACT NAME: �/Ti CONTACT PHONE: 4z,� 330 /ti.5-4> <br /> �/Z-gW r f �v-r22i S CONTACT EMAIL: Cj Vel✓I i'�� ec'tc,G�J (� �'1�IQ r L : CA44,-I <br /> AGREEMENT:I hereby certify that I 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 C r for <br /> which applica tt Officiation l s made and I <br /> comply with the State Contractors Law 18.27 RCW and 296.200 WAC. ty of PERMIT#: 30 <br /> /a 2te (Revised 1/11/2019) Page 1-Application <br /> Own thonzed Agent Signature D <br />