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EJCTRICAL PERMIT APPLITION <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 INFORMATION <br /> PROJECT ADDRESS: //0 jjt /9-t+1 /e $< BUILDING AREA: sq ft <br /> PROJECT TYPE: El NEW CONSTRUCTION ❑ADDITION ❑TENANT IMPROVMENT ❑ REMODEL <br /> BUILDING USE: ❑SFR ❑TOWNHOUSE El DUPLEX ❑ADU El MULTI-FAMILY-#OF UNITS: ❑ COMMERCIAL <br /> ELECTRICAL APPLICATION INFORMATION & DESCRIPTION OF WORK <br /> CONTRACT PRICE OF WORK:$ 0 ASSOCIATED BUILDING PERMIT#(if applicable): <br /> DESCRIBE SCOPE OF WORK: y15---f-rkil GleNaAmf, f t � S <br /> 6ln e LA A I( <br /> THIS INSTALLATION INCLUDES THE FOLLOWING SCOPE: (SELECT ALL THAT APPLY) <br /> LINE VOLTAGE WORK? [NO El YES-Select Scope: ❑ Service Cl Feeder ❑ Circuits-#: ❑Complete Re-wire <br /> LOW VOLTAGE WORK? ❑ NO RYES-#of Devices: <br /> SELECT SCOPE(REQUIRED): El Data El Intercom El Thermostat ❑Audio El Secure Access El 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 /> LJ Other(List All): 5 p 6:"\ <br /> CODE COMPLIANCE <br /> IS THIS PERMIT EDUCATION,INSTITUTIONAL,HEALTH AND/OR PERSONAL CARE FACILITIES: iNO El YES—See Below&Pg.2 <br /> E By checking this box,I am stating that I have read and understand all of WAC 296-468-900,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: LWINO EYES-See Below&Pg.3 <br /> El 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—f-jA) Sr...,Alov. TENANT BUSINESS NAME(If Commercial): I ,,,,y.; <br /> OWNER MAILING ADDRESS: STREET F c) 1QY 13 9 3 <br /> CITY m/( STATE 'A zip <br /> OWNER PHONE: 'OWNER EMAIL: <br /> CONTRACTOR NAME: 1�- 6 1•S S <br /> CONTRACTOR ADDRESS: STREET /9/a I„l�/ 9q ¢f' <br /> ASTATEWIN- ZIP ° (S3136 <br /> CONTRACTOR PHONE: 425-2.73—Onq 1CONTRACTOR EMAIL: 5 s�.3� y�L C dYt�j <br /> CONTRACTOR LIC.#(REQUIRED): )�-( C�X3 CITY OF EVERETT BUSINESS LIC.OtEQUIRED): 53cf _o <br /> PRIMARY CONTACT: El OWNER el CONTRACTOR ❑OTHER(Please Specify) <br /> CONTACT NAME: CONTACT PHONE: 4-_S3 —oo9 Z <br /> j:6 eS 2i CONTACT EMAIL: �.y�•�i 4 6 <br /> AGREEMENT:I hereby certify t aH t l have read and examined this application and know the sa/Tie g1�'Jbe tru and d cohect. All prof s of laws and ordinances governing this <br /> type of work will be completed whether specified herein or not. The granting of a permit does notpresumd 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 /> _ 9_ E 2JO6 .- HHO <br /> 0 Agent Signature Date I � (Revised 1/11/2019) Page 1-Application <br />