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• • <br /> ELECTRICAL PERMIT APPLICATION <br /> '�' CITY OF EVERETT PERMIT SERVICES <br /> �-�-i 3200 CEDAR STREET,EVERETT,WA 98201 <br /> s " (P)425-257-8810 I FAX 425-257-8857 I(E)everetteps@everettwa,gov I www.everettwa.gov/permits <br /> .PROJECT`SITE INFORMATION <br /> l� - (PROJECT ADDRESS:lk I - BUILDING AREA: sq ft <br /> PROJECT TYPE: 0 NEW CONSTRUCTION El ADDITION RTENANTIMPROVMENT 0 REMODEL <br /> BUILDING USE: ❑SFR 0 TOWNHOUSE ❑DUPLEX ❑ADU ❑MULTI-FAMILY-#OF UNITS: atCOMMERCIAL <br /> ELECTRICAL APPLICATION:INFORMATION,.&\DESCRIPTION OF,WORK <br /> CONTRACT PRICE OF WORK:$ �,, "— ASSOCIATED BUILDING PERMIT#(if applicable): <br /> DESCRIBE SCOPE OF WORK: Q \ ) 'l"e\ 6\ Aik? 1 6- \,c(' .fit( Q. e \ ( <br /> CkCVV\\(S '.13)cle4 vsL,_ <br /> THIS INSTALLATION INCLUDES THE FOLLOWING SCOPE:(SELECT ALL THAT APPLY) <br /> LINE VOLTAGE WORK? ❑NO 0 YES-Select Scope: ❑Service 0 Feeder 0 Circuits-#: ❑Complete Re-wire <br /> LOW VOLTAGE WORK? 0 NO YES-#of Devices: tgt <br /> SELECT SCOPE(REQUIRED): 0 Data 0 Intercom ❑Thermostat 0 Audio 0 Secure Access 0 Security System <br /> gikti,re 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: NO ❑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 OWNER PERFORMING WORK AS THE CONTRACTOR WITHOUT ELECTRICAL LICENSURE: NO OYES-See Below&Pg.3 <br /> AN <br /> ❑ Pursuant to RCW 19.28.261,property owners and leaseholders cannot perform electrical work on buildin s 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: TENANT BUSINESS NAME(If Commercial):c\ )p-� _ <br /> A A <br /> OWNER MAILING ADDRESS: STREET - U\ k.a( .k. .4 (� <br /> CITY F„��`\ f`p <br /> STATE \NA ZIP (2 l_ ty <br /> OWNER PHONE:l c4 s 1 OWNER EMAIL <br /> CONTRACTOR NAME: LeAv1mt-),tccI\ ' ) L'vk'.i <br /> CONTRACTOR ADDRESS: STREET l 1 7) \ -A'1'.-(> <br /> CITY ` Z STATE L\NA ZIP 13+ <br /> CONTRACTOR PHONE: U 1..2" (OS," CONTRACTOR EMAIL: ( ((`\\,'>N)v C C ct v\' �(i t � .ft y.. <br /> r CITY OF EVE ETT'BUSINESS 1.1C.#(REQUIRED):i 1 -' ' 7) <br /> CONTRACTOR LIC.#(REQUIRED)a i� � �� _� .... _. A , <br /> PRIMARY CONTACT: ❑OWNER r4ONTRACTOR 0 OTHER(Please Specify) <br /> CONTACT NAME: CONTACT PHONE: pl ((�C —7gt-k-Lf <br /> A' -.tY , ��1q).lI �fUMA CONTACT EMAIL:C r(\(` t. V `�,,A f(uckt in:v C t t it1 cow <br /> At REEMENT:I hereby certify t of I h e read and examined this application and know the same tcVbe t and correct. Al provisions of laws and ordinance 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 /> ti r--- (2 2_ L E Z 2 o 2,— 241 <br /> � d 'ge t l (Revised 1/11/2019) Page 1-Application <br /> OwnerlAut onzed�gent Si nature Date g pp <br />