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• • <br /> izi ELECTRICAL PERMIT APPLICATION <br /> EVERETT CITY OF EVERETT PERMIT SERVICES <br /> 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 INFORMATIOII# ; ,; <br /> PROJECT ADDRESS: L `a O J , (;P BUILDING AREA: €t F) ..,2-1 - sq ft/0� 4 <br /> PROJECT TYPE: ❑ NEW CONSTRUCTION ❑A 4TION gi TENANT IMPROVMENT ❑ REMODEL <br /> BUILDING USE: ❑SFR ❑TOWNHOUSE ❑ DUPLEX ❑ADU ❑ MULTI-FAMILY-#OF UNITS: I COMMERCIAL <br /> ELECTRICAL APPLICATION INFORMATI,OAI +& DESC,RIPTION OF(WORK <br /> CONTRACT PRICE OF WORK:$ )000 ASSOCIATED BUILDING PERMIT#(if applicable): <br /> DESCRIBE SCOPE OF WORK: 4 Q <br /> tc2._ j:k i <br /> --A:-'014 0, c.0_,,,L_ _I <br /> ',LAID" %L2, ',..}-v- 0 <br /> , egi\A A <br /> THIS INSTALLATION INCLUDES THE FOLLOWING SCOPE: (SELECT ALL THAT APPLY) <br /> LINE VOLTAGE WORK? ❑ NO 6 YES-Select Scope:❑Service ❑ Feeder ❑Circuits-#: ❑Complete Re-wire <br /> LOW VOLTAGE WORK? ❑ NO gfl YES-#of Devices: 3 f <br /> SELECT SCOPE(REQUIRED): ❑ Data ❑ Intercom ❑Thermostat ❑Audio El 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 /> CODEAONIPLIANCE. <br /> IS THIS PERMIT EDUCATION,INSTITUTIONAL,HEALTH AND/OR PERSONAL CARE FACILITIES: NO El YES--See Below&Pg.2 <br /> I l 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: INO EYES-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: CT r$Gb O J I— TENANT BUSINESS NAME(If Commercial): ilL)ke...„, <br /> OWNER MAILING ADDRESS: STREET 1, 9 00 L3 _B\,d()u cQ/1 $±' <br /> CITY ,, % '- ' STATE I LJCk., ZIP V/` 7 <br /> OWNER PHONE: L 5 1: Vt i ;: OWNER EMAIL: U0 P Pit R..:Je{' Se ell Q-lt;C± / !r5 s 1 ( ...,. <br /> CONTRACTOR NAME: )-%0 �,• - <br /> �'t_C'S2N\ <br /> CONTRACTOR ADDRESS: STREET 6O 0 L I U i Lke K 0 n 5 <br /> cm( (?9,1QptithL STATE ZIP <br /> CONTRACTOR PHONE: (A).y)")/3--0 pig CONTRACTOR EMAIL: j oe- e ceiIU' -*(,G oo CS'ff r7cS.c,_za m. <br /> CONTRACTOR LIC.#(REQUIRED) III/ \CTF15 Ct0 11 C H CITY OF EVERETT BUSINESS LIC.#(REQUIRED I O I <br /> PRIMARY CONTACT: ]OWNER ❑CONTRACTOR ❑OTHER(Please Specify) <br /> CONTACT NAME: CONTACT PHONE: C2 / 3_0/ - <br /> -O Cr ,��0r �` CONTACT EMAIL: io e(}e oPp nejec 7�9 oLC.co <br /> AGREEMENT.:I hereby certify that I have read and examined this application and know the same to be true and ct. All provisions of laws and orylinances 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 Wan 296.200 WAC. City of Everett Official Use Only <br /> PERMIT#: <br /> A <br /> Owner/Authorized ig ture Date (Revised 1/11/2019) Page 1-Application <br />