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4111 • <br /> ELECTRICAL PERMIT APPLICATION <br /> CITY OF EVERETT PERMIT SERVICES <br /> EVERETT 3200 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/permits <br /> PROJECT SITE INFORMATION, <br /> PROJECT ADDRESS:r .12C/ U'IG Ta2Z I u``(,_ BUILDING AREA: `4-1lYc' sq ft <br /> PROJECT TYPE: CINEW CONSTRUCTION ElADDITION ElTENANT IMPROVMENT E REMODEL <br /> BUILDING USE: ❑SFR ❑ TOWNHOUSE ❑ DUPLEX ❑ADU ❑ MULTI-FAMILY-#OF UNITS: 7 COMMERCIAL <br /> ELECTRICAL APPLICATION INFORMATION & DESCRIPTION OF WORK <br /> CONTRACT PRICE OF WORK:$ ,� E C� ASSOCIATED BUILDING PERMIT#(if applicable): <br /> DESCRIBE SCOPE OF WORK: Qcc <br /> THIS INSTALLATION INCLUDES THE FOLLOWING SCOPE: (SELECT ALL THAT APPLY) <br /> LINE VOLTAGE WORK? ❑ NO ..7" YES-Select Scope: ❑ Service ❑ Feeder l71 Circuits-#: / ❑ Complete Re-wire <br /> LOW VOLTAGE WORK? ❑ NO ❑YES-#of Devices: <br /> SELECT SCOPE(REQUIRED): <br /> ❑ 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: 0-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. l-�� <br /> ARE YOU AN OWNER PERFORMING WORK AS THE CONTRACTOR WITHOUT ELECTRICAL LICENSURE: ENO ❑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:,INFORMATION <br /> OWNER NAME: TENANT BUSINESS NAME(If Commercial): 61,+'1 C'1 C� £(17,,ectt <br /> OWNER MAILING ADDRESS: STREET <br /> CITY STATE ZIP <br /> OWNER PHONE: (OWNER EMAIL: <br /> � n t <br /> CONTRACTOR NAME: C \ G�L'� `�— �' `("— <br /> CONTRACTOR ADDRESS: STREET l z 2 4^ • S``- try <br /> 117 //r CITY 0/C4-_ STATE ZIP <br /> CONTRACTOR PHONE: CONTRACTOR EMAIL: Z i V1/l C' C clue(n I i A r <br /> CONTRACTOR LIC.#(REQUIRED): �LS/ 1 F7 ICITY OF EVERETT BUSINESS LIC.#(REQUIRED) <br /> PRIMARY CONTACT: DOWNER ET-CONTRACTOR ❑OTHER(Please Specify) <br /> CONTACT <br /> NAME: CONTACT PHONE: yt 2 <br /> CONTACT EMAIL: '7 (Y7, h675 k 727,`.,4 CCCL"I <br /> AGREEMENT:1 hereby certify that 1 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 wCitrk y for <br /> r which <br /> pp is atil n s madl is e and I <br /> comply with the State Contractors Law 18.27 RCW and 296.200 WAC. PERMIT#: <br /> n 1 E IC) 0'1 — \ Le) <br /> dven uth orized Agent Signature <br /> Date <br /> (Revised 1/11/2019) Page 1-Application <br /> Auth <br />