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10 • <br /> ELECTRICAL PERMIT APPLICATION <br /> CITY OF EVERETT PERMIT SERVICES <br /> EVERETT <br /> 3200 CEDAR STREET,EVERETT,WA 98201 <br /> WAIHINO-roN (P)425-257.8810 I FAX 425.257.8857 ((E)everettepa6everettwa gov I vww.everettwa.gov/permits <br /> PROJECT SITE INFORMATION <br /> PROJECT ADDRESS: 1 ,�� ,SZ�-y.� � ta,� E- v, BUILDING AREA:, sq ft <br /> PROJECT TYPE: ❑NEW CONSTRUCTION ❑ADDITION ❑TENANT IMPROVMENT ❑REMODEL <br /> BUILDING USE: ❑SFR 0 TOWNHOUSE ❑DUPLEX ❑ADU ❑MULTI-FAMILY•#OF UNITS: ❑COMMERCIAL <br /> ELECTRICAL APPLICATION INFORMATION & DESCRIPTION OF WORK <br /> CONTRACT PRICE OF WORK:$ P3C3 k•-‘ ASSOCIATED BUILDING PERMIT#(if applicable) <br /> DESCRIBE SCOPE OF WORK: = R <br /> THIS INSTALLATION INCLUDES THE FOLLOWING SCOPE:(SELECT ALL THAT APPLY) <br /> LINE VOLTAGE WORK? ❑NO ❑YES-Select Scope:❑Service ❑Feeder ❑Circuits-#: ❑Complete Rewire <br /> LOW VOLTAGE WORK? ❑NO Q YES-#of Devices:c C <br /> SELECT SCOPE(REQUIRED). ❑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 approva, <br /> ❑Other(List AIL):_ <br /> CODE COMPLIANCE <br /> IS THIS PERMIT EDUCATION,INSTITUTIONAL,HEALTH AND/OR PERSONAL CARE FACILITIES: ❑NO n YES—See Below&Pg.2 <br /> — By checking this box,I am stating that I have read and understand all of WAC 298-48B-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 fol,owing 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: ONO DYES-See Below& Pg 3 <br /> 111 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: T >U::7 A`-A TENANT BUSINESS NAME(If Commercial): -wont <br /> OWNER MAILING ADDRESS: STREET C.s�V(� , \ (S? <br /> CITY STATE ZIP <br /> OWNER PHONE: -,Q --i •01-k\ ,OWNER EMAIL: <br /> CONTRACTOR NAME:V tip `k �.,,.�-h-C. `,ail '- C:$V\V <br /> CONTRACTOR ADDRESS: STREET \�V C) V <br /> CITY i \ STATEt \) ZIP CI <br /> CONTRACTOR PH ` t,pL-1 SONTRACTOR EMAIL: \' C-A. VZ1� 1 C-`-� L ,t�` -t • Ct ' (/�/ <br /> CONTRACTOR LIC.#(REQUIRED):�)�t �,l{�r ._cam \ _CITY OF EVERETT BUSINESS\IC.#EQUIRED).C))C\D"i <br /> PRIMARY CONTACT: [DOWNER ,CONTRACTOR ❑OTHER(Please Specify) <br /> CONTACT NAME: CONTACT PHONE:�'�t( , (b <br /> \` Y,k.1. ‘ CONTACT EMAIL: I `�l .A :�1 -.``� C `�L <br /> AGREEMENT:I hereby certify that I have read and examined this application and know the same to be true and correct. Au prov lions or laws and ordinancest govern a this <br /> type of work wilt be completed whether specified herein or not. The granting of a permit does not presume to give author:1y to violate or cancel the provisions of any other stale or <br /> local law regulating construction or the performance of construction. That I am authorized by the owner of this properly to perform the work for which application Is made and I <br /> comp!),with the State Contractors Law 18.27 RCW and 226.200 WAC. City of Everett Official Use Only <br /> PERMIT#: <br /> E '2ccD — S <br /> -0tivner/Authorilted A ent Signature Date (Revised t/f1/2019.) Page 1-Application <br />