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<br /> ELECTRICAL PERMIT APPLICATION
<br /> E V E R E T T 32 CITY OF EVERETT PERMIT SERVICES
<br /> 00 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/per iitts�
<br /> PROJECT SITE INFORMATION rr�� jj 'C1
<br /> ft PROJECT ADDRESS: c ; Y A 06(I'c i e lJJ BUILDING AR A: 32' 14 toq r''
<br /> PROJECT TYPE:X NEW CONSTRUCTION ❑ADDITION ❑TENANT IMPROVMENT ❑ REMO
<br /> BUILDING USE: ❑SFR Cl TOWNHOUSE DUPLEX ❑ADU El MULTI-FAMILY-#OF UNITS: ❑ COMMERCIAL
<br /> ELECTRICAL APPLI ATION INFORMATION`'& DESCRIPTION OF WORK;,
<br /> CONTRACT PRICE OF WORK:$ t'-; c,c ASSOCIATED BUILDING PERMIT#(if applicable): VSOitC
<br /> DESCRIBE SCOPE OF WORK: �) -4-w vii., 4 Li, I 4'L Zoo
<br /> . v( (.( C)ve/ [(lead , w i -i-, t$ ) ?.c A-r- ? 19,-k.e_Is, A--4- 'CZ? ,
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<br /> THIS INSTALLATION INCLUDES THE FOLLOWING SCOPE: (SELECT ALL THAT APPLY)
<br /> LINE VOLTAGE WORK? ❑NO YES-Select Scope: ___Service Feeder El Circuits-#: El Complete Re-wire
<br /> LOW VOLTAGE WORK? ❑ NO YES-#of Devices: fff I Z► ,
<br /> SELECT SCOPE(REQUIRED):Data El Intercom ❑Thermostat El Audio ❑Secure Access El Security System
<br /> El 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'COMPLIA . CE`;
<br /> IS THIS PERMIT EDUCATION,INSTITUTIONAL,HEALTH AND/OR PERSONAL CARE FACILITIES: NO in YES--See Below&Pg.2
<br /> By checking this box,I am stating that I have read and understand all of WAC 296-46B-90 ,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: 0 DYES-See Below&Pg.3
<br /> Pursuant to RCW 19.28.261,property owners and leaseholders cannot perform electrical work on uildings 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):
<br /> OWNER MAILING ADDRESS: STREET
<br /> CITY STATE ZIP
<br /> OWNER PHONE: OWNER EMAIL:
<br /> CONTRACTOR NAME: )i� J '' )_(;' \ L L
<br /> CONTRACTOR ADDRESS: STREET £ 4-eyvki vCITY rA STATE 1JPZIP 5e zCONTRACTOR PHONE: `y 2J��% - �{OOTOR EMAIL: �C,4t' (-/'C ' 9/�?t-1 J. �.C)eLi
<br /> CONTRACTOR LIC.#RE UIRED: ' 6 CITY OF EVERETT BUSINESS LIC.#REQUIRED
<br /> ( Q ) 5 h��� f 31�S 5 4.6523
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<br /> PRIMARY CONTACT: DOWNER $CONTRACTOR ❑OTHER(Plea Specify)
<br /> CONTACT NAME: CONTACT PHONE: ll?'5) ',Q (.(^ o 2
<br /> (e1 — nQcJJL-- CONTACT EMAIL: i/ f/Pc L 0(C )c )-)l( I 1 L �,LI
<br /> A REEMENT:I hereby c rti at l have read and examined this application and know thefsame to be/rue and correct. All provisions of laws adinances governing this
<br /> 4'
<br /> type of work will be complete hether 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 /> /1-‘-.-- g' E n 09 - � � 3
<br /> Owner/Authorized Agent Signature ate (Revised 1/11/2019) Page 1-Application
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