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ELECTRICAL PERMIT APPLICATION <br />EVERETT 32CITY OF EVERETT PERMIT SERVICES <br />00 CEDAR STREET, EVERETT, WA 98201 <br />WASHINGTON (P) 425-257-8810 1 FAX425-257-8857 1 (E) everetteps@everettwa.gov I www.everettwa.gov/permits <br />PROJECT ADDRESS: rL <br />BUILDING AREA: sq ft <br />PROJECT TYPE: ❑ NEW CONSTRUCTION ❑ ADDITION TENANT IMPROVMENT ❑ REMODEL <br />BUILDING USE: ❑ SFR ❑ TOWNHOUSE ❑ DUPLEX ❑ ADU ❑ MULTI -FAMILY - # OF UNITS: COMMERCIAL <br />ELECTRICAL FL,,!!C 1,QN 1.N�ORMATIION_ �&. DESCRtRT-C <br />CONTRACT PRICE OF WORK: $ ASSOCIATED BUILDING PERMIT # (if applicable): <br />DESCRIBE SCOPE OF WORK: <br />h <br />mb I Ia <br />I I - Oa . <br />THIS INSTALLATION INCLUDES THE FOLL WING SCOPE: (SELECT ALL THAT APPLY) <br />LINE VOLTAGE WORK? ❑ NO YES - Select Scope: ❑ Service ❑ Feeder ❑ Circuits-#: / ❑ Complete Re -wire <br />LOW VOLTAGE WORK? ❑ NO YES- # of Devices: <br />SELECT SCOPE (REQUIRED): ❑ 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): lr LL' w ;: t'4 iV r2= S <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 296-4613-900, 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 YOY AN OWNER PERFORMING WORK AS THE CONTRACTOR WITHOUT ELECTRICAL LICENSURE: ONO [2YES -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 />ED 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 />> CON'i'ACT�INFORMi�T10N ,.5�., <br />OWNER NAME: TENANT BUSINESS NAME (If Commercial): <br />OWNER MAILING ADDRESS: STREET ! - r •-(V) vy S,' <br />1 / <br />CITY I w t t S N STATE V ZIP ` Z` 1✓ <br />OWNER PHONE: ' ( Z <br />OWNER EMAIL: <br />CONTRACTOR NAME: U'1T ­ OF <br />CONTRACTOR ADDRESS: STREET <br />CITY STATE - ZIP <br />CONTRACTOR PHONE: <br />CONTRACTOR EMAIL: <br />CONTRACTOR LIC. #(REQUIRED): <br />CITY OF EVERETT BUSINESS LIC. #(REQUIRED): <br />PRIMARY CONTACT: DOWNER. ❑CONTRACTOR ❑OTHER (Please Specify) <br />CONTACT NAME: <br />CONTACT PHONE: <br />CONTACT EMAIL: <br />AUhlttM N l: r nereDy cemty rnat r nave reaa ana exammea mrs appucaoon ana Know me same to oe rrue ana correcr. Hn pruvrs MS yr rewi ano orunranccs yvvonmry 1 u0 <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/ <br />comply w1 the State Contractors Law 18.27 RCW and 296.200 WAC. City of Everett Official Use Only <br />PERMIT #: <br />.;✓ E-7,3p1-0 <br />OwnerlAire Date (Revised 111112019) Page 1-Application <br />