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'. /op <br /> ECTRICAL PERMIT <br /> MIT S <br /> APPLI TION <br /> CITY OF EVERETT PER SERVICE <br /> - a y- 3200 CEDAR STREET,EVERETT,WA 98201 <br /> _/ (P)425-257-8810 f FAX 425 257 8857 (E)everetteps@everettwa.gov( www.everettwa.gov/permits <br /> PROJECT SITE INFORMATION <br /> PROJECT ADDRESS: /d .342 jiy BUILDING AREA: sq ft <br /> PROJECT TYPE: Ci 'NEW CONSTRUCTION ❑ADDITION ❑TENANT IMPROVMENT ❑ REMODEL <br /> BUILDING USE: ❑SFR El TOWNHOUSE El DUPLEX ❑ADU ❑MULTI-FAMILY-#OF UNITS: I(OMMERCIAL <br /> ELECTRICAL APPLICATION INFORMATION & DESCRIPTION OF WORK <br /> CONTRACT PRICE OF WORK:$911f, ' , Id7 ASS CIATED BUILDING PERMIT#(if applicable): <br /> DESCRIBE SCOPE OF WORK: Z A)sue/?t(,/v` �(I\3 �eZ€_ ,7Z `e S4/ e11 %Li - esseAle,e_ (2.vry 7-e.) 72_9_‘..e, <br /> , 0 tit,IOC 412 I • . frri.....„ efle2J4 if <br /> THIS INSTALLATION INCLUDES THE FOLLOWING SCOPE: (SELECT ALL THAT APPLY) <br /> LINE VOLTAGE WORK? ❑NO YES-Select Scope: ❑Service El Feeder ®Circuits-#: 3 El Complete Re-wire <br /> C7) c 1 y ,p7 4/ /2O ,f17 / ✓-�,,y .5 <br /> LOW VOLTAGE WORK? El NO ( 'YES-#of Devices: � / '� <br /> SELECT SCOPE(REQUIRED): ❑Data ❑Intercom ❑Thermostat ❑Audio ❑Secure Access ❑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 /> ❑Other(List All): <br /> CODE COMPLIANCE <br /> IS THIS PERMIT EDUCATION,INSTITUTIONAL,HEALTH AND/OR PERSONAL CARE FACILITIES: 1 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 AN OWNER PERFORMING WORK AS THE CONTRACTOR WITHOUT ELECTRICAL LICENSURE: LbNO EYES-See Below&Pg. 3 <br /> fl 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: S' R /<Lej,✓ I;s1 —11i1/ I AA/psT' ii BUSINESS NAME(If Commercial): <br /> OWNER MAILING ADDRESS: STREET /)0.sox 3/3 0 <br /> CITY Cj il (7 STATE kJ f• ZIP 98 9/3 <br /> OWNER PHONE: 4 ,jtS 3,5-b ricD D OWNER EMAIL: to %7 4>Ajei 1)10,07),4',_'o#2, <br /> CONTRACTOR NAME: S% Cr Al MAXI <br /> — <br /> CONTRACTOR ADDRESS: STREET /CJ 5.-h ,/eee.4J yy .j,�//)� <br /> CITY A-1�e� �jJ4). (1 / STATE ZIP 7 S <br /> CONTRACTOR PHONE: 3 --`f,77 g`// 9 CONTRACTOR EMAIL: (Pi t 7a S i-ppNj gr.&54,C'v/? <br /> CONTRACTOR LIC.#(REQUIRED):CC$J6-0v L, f a? T3 CITY OF EVERETT BUSINESS LIC.#(REQUIRED): ' F9 bit_ <br /> PRIMARY CONTACT: DOWNER IlEtSNTRACTOR DOTHER(Please Specify) <br /> CONTACT NAME: CONTACT PHONE: 3(0 — $2g--- V g 9,r <br /> (? r ---1-:-'-/; CONTACT EMAIL: G'"./�•T a;cu /II`hf.re z/s�-,e per? <br /> AG EEMENT: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 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 /> E 2Iocjq <br /> Owner/Authorized Age Signature Date (Revised 1/11/2019) Page 1-Application <br />