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n' <br /> ELECTRICAL PERMIT APPLICATION <br /> EVERETT CITY OF EVERETT PERMIT SERVIGES <br /> 3200 CEDAR STREET,EVERETT,WA 90201 <br /> WAOMOTON (P)426.267-11010 1 FAX 426-267-0967 1(E)overellep$l@ovorottwa.govI wwvr.ovorottwa.9ov1poM1It8 <br /> yaWIE p /9 , <br /> PROJECT A13DRESS: 10521 19th Ave SE Suite 100 13UiLDINGi AREA:1600 aq ft <br /> PROJECT TYPE: d NEW CON5TAUCTiON n ADDITION -1 TF IMPROVMENT n REMODEL <br /> BUILDING USE: n SFR n TOWNHOUSE n DUPLEX n ADU n MULTIFAMILY-#OF UNITS: 2 COMMERCIAL <br /> W C:IMICII��,.i�lP!PILECAIrRQ�1INI O.�IMAT.1ON Ba=g)l CSC PXIO :OR'':1 0 <br /> CONTRACT PRICE OF WORK:$ 9850.00 JASSOCIATED BUILDING PERMIT#(if applicable): 82102-035 <br /> DESCRIBE SCOPE OF WORK; <br /> for Restaurant-new leaf pho <br /> THIS INSTALLATION INCLUDES THE FOLLOWING SCOPE: SELECT ALL THAT APPLY) <br /> LINE VOLTAGE WORK? n NO 0 YES-Select Scope'.0 Service n Feeder n ClrcuEls•#; ©Complete Re-wire <br /> LOW VOLTAGE WORK? n NO n YES-#of Devices: <br /> SELECT SCOPE(REQUIRED):n Data n Intercom Q Thermostat Q Audio n Secure Access ❑Security System <br /> ✓n Piro Alarm-Installations under this permit only include electrical wifing rough-In of the system.An additional <br /> Fire Maim Permit Is required for review of device location and Installation approval. <br /> El Other(List All): <br /> WOOF" V 777" -7777777777' <br /> IS THIS PERMIT EDUCATION,INSTITUTIONAL,HEALTH ANDIOR PERSONAL CARE FACILITIES: LJNO YES—See below&Pg.2 <br /> By checking this box,I am staling that I have read and undersland all of WAC 296.408-900,selected the specific reason on page 2 <br /> of this appfioatlon(see next page),AND Pian Review Is NOT required because I meet 811 of the following sub Sections that do not <br /> see Paso 2 require Plan Review. <br /> ARE YOU AN OWNER PERFORMING WORK AS THE CONTRACTOR WITHOUT ELECTRICAL LICENSURE:ONOEIYES-See Below&Pg.3 <br /> EEli Pursuant to ROW 19.26.261,property owners and leaseholders cannot perform electrical work on buildings for rent,sale,or lease <br /> l without the proper electrical licensing and certification,or exemption.By cltecking this box,I am slating 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/ceTlIfIcatlon requirement. <br /> Cd$N' Mt."T`: lFOR�411A"1"HO_ .-. 77777-777777 <br /> OWNER NAME: kin wa Chap TENANT BUSINESS NAME if commercial): New Leaf Pho <br /> OWNER MAILING ADDRESS: sntreT 1432 173Rd SW <br /> C, Lynnwood aTATE WA 98037 <br /> OWNER PHONE.:3609900836 OWNER EMAIL:bluewhatechemical@gmail.com <br /> CONTRACTOR NAME: kin wa Chan <br /> CONTRACTOR ADDRESS: IIEET1432173rd SW <br /> cuy Lynnwood STATE WA aP 98037 <br /> CONTRACTOR PHONE-3609900836 CONTRACTOR EMAIL,bluewhalechemical@gmail.com <br /> CONTRACTOR LIC.fl REQUIRED: CITY OF EVERETT BUSINESS LIC,fl(REQUIRED):62990 <br /> PRIMARY CONTACT: pOwNER n✓CONTRACTOR ❑OTHER(Please Specify) <br /> CONTACT NAME: CONTACT PHONE:3609900836 <br /> kin wa chan CONTACTEMAIL:bluewhalachemicalQagmall.com <br /> AdREEMEN :l bore y Corti y lhot f ave roe err oxondne this appocavon Rao know ft some to bo fate an=d. Al provlsfons of laws and O—A+nancos povoming INS <br /> type of work"Id bo corapleled wheUrer spoofed hereln or not. The granitng of a permll does not presume to siva ardhority to vlolate or concelllre provisions or any other slate or <br /> tocellew regulotlny oonslrrrcllon Ortho perfomranco o!corrstruclla+. That 1 om outhodzed try the ownerol fhls pmpedyto psrform the work forwhkh apptkotton 19 made and/ <br /> comply with the Stole Conlraclors I.aW 10.27 RCINend 29A200 WAC, City of Everott Otltclal Use Onl <br /> PERMIT f: <br /> w _ zL E <br /> OwnerlAuthorizod Agent Signature Dale (Rovfsod 111112019) Page 1-Appticalloh <br />