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<br /> ELECTRIC ,L PERMIT APPLICATION
<br /> CITY OF EVERETT PERMIT SERVICES
<br /> IA' 3200 CEDAR STREET,EVERETT,WA 98201
<br /> (P)425-257-8810 I FAX 425-257-8857 I(E)everetteps@everettwa.gov I www.everettwa.gov/permits
<br /> ,,PROJECT SITE<INPORMATICN
<br /> PROJECT ADDRESS: 3.,7 2,1 INICA BUILDING AREA: sq ft
<br /> PROJECT TYPE:p NEW CONSTRUCTION ❑ADDITION 0 TENANT IMPROVMENT ❑REMODEL
<br /> BUILDING USE: ❑SFR ❑TOWNHOUSE ❑ DUPLEX 0 ADU iit MULTI-FAMILY-#OF UNITS: 0 COMMERCIAL
<br /> ELECTRICAL APPLICATION;INFORMATION 4,;DESCRIPTION.OF WORK .`
<br /> CONTRACT PRICE OF WORK:$ &,/3 , iL' Th ASSOCIATED BUILDING PERMIT#(if applicable): 6 1 g c) (1)-D
<br /> DESCRIBE SCOPE OF WORK: "re- p PP-tom.; F..DP - N E v ;
<br /> THIS INSTALLATION INCLUDES THE FOLLOWING SCOPE: (SELECT ALL THAT APPLY)
<br /> LINE VOLTAGE WORK? ❑NO 0 YES-Select Scope:ix Service 0 Feeder ❑Circuits-#: ❑Complete Re-wire
<br /> LOW VOLTAGE WORK? ❑NO 0 YES-#of Devices:
<br /> SELECT SCOPE(REQUIRED): ❑Data ❑ Intercom ❑Thermostat ❑Audio 0 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 7.,'.. .:...':
<br /> IS THIS PERMIT EDUCATION,INSTITUTIONAL,HEALTH AND/OR PERSONAL CARE FACILITIES: NO 0 YES--See Below&Pg.2
<br /> D 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: NO OYES-See Below&Pg. 3
<br /> D 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: SSA L_ 7r t(2j I t-TENANT BUSINESSNAME(If Commercial):
<br /> OWNER MAILING ADDRESS: STREET .7 7') ` _N;/ AVE i 1TE , ?0'
<br /> CITY C.� '` 1 STATE �.`j'A ZIP ', J Z ))
<br /> OWNER PHONE 4 ZS_ Z>-Z 7 �� OWNER EMAIL: /
<br /> .:...`,...,, ......:._ .�,.....,...........:....\..n .... a ...«w.x•«v ........a,.... ...,.....a.,....t <<.....:..»::.._:...... :, :.. -:.+.�,.au.•i..T3Y,...,a,,.�:...<-.. ,aa3r.....::.,,..+..........v.....,.,..m ...«s�s..a;;F.;... . a.n.,.... .. ..�. ..at.re..n.a 3..v`t>,�................. ,..x..x`�
<br /> CONTRACTOR NAME: 1( `j s`kli dCL c__. --g_le.,' L ° -)
<br /> CONTRACTOR ADDRESS: STREET F'O) GDX :) 1
<br /> CITY e�G�` `STATE /\,) " ZIP
<br /> CONTRACTOR PHONE:142. '3!23C) CONTRACTOR EMAIL:
<br /> CONTRACTOR LIC #(REQUIRED) % 7'7 PL CITY OF EVERETT BUSINESS LIC #(REQUIRED) � '
<br /> i3 j(Q-5—
<br /> PRIMARY CONTACT: ❑OWNER 1gCONTRACTOR 0 OTHER(Please Specify)
<br /> CONTACT NAME: CONTACT PHONE: Liz._7 1 —z3c-r7
<br /> Q131 1 _fac— 1/\ CONTACT EMAIL:
<br /> AGREEMENT: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 tate Contractors Law 18.27 RCW and 296.200 WAC. City of Everett Official Use Only
<br /> PERMIT#:
<br /> i C_ /c.' E \ot ID- 0(o0
<br /> Owner/Au • gent Signature Date / (Revised 1/11/2019) age 1-Application a
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