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ELECTRICAL PERMIT APPLICATION
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<br /> ri- ..__ UUILt11H0 AREA: ')( \ T C`t�,2E.RC�
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<br /> A900C►Al1a0 HU11-0I110 PEt41411 M(d npp!icnblo)
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<br /> i lllti IVSTALLAIIi!N INc:LUI_)_I S )HE FOLLOWING SCOPE: SELECT ALL THAT APPLY
<br /> 1110,�'00 Ali t:WOI%K T ❑NO ❑YES-Select Scope: ❑ Service ❑ Feader ❑Circults•1t; _ ❑Complete Re-wlro
<br /> LOW 1 OLIA61.1VOI:K7— - ❑ No 1AYES•a of Devices:
<br /> I Lt;CT SC0l1L tt;:,la!lit u): ❑ Data ❑Intercom ❑ Thermostat ❑Audio ❑Secure Access ❑Security System
<br /> ❑ File Alarm-Installations under this permit only include electrical wlring rough-in of the system.An additional
<br /> Fltu Alarm Permit Is required for review of device location and installation approval,
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<br /> IS i ti;S PERMIT EDUCATION,INSTITUTIONAL,HEALTH AND/OR PERSONAL CARE FACILITIES: fXbO Ll YES—See Below&Pg,2
<br /> ❑ By chez.Ning this box, I am staling that I have road and understand all of WAC 296-46B•900,selected tho spocifle reason on pago 2
<br /> of this application(goo noxt pago),AND Plan Review Is NOT required because I moot all of the following sub sections that do not
<br /> Pt,,•,e 2 r Plan Review.
<br /> ARE YOU AN OWNER PERFORMING WORK AS THE CONTRACTOR WITHOUT ELECTRICAL LICENSURE: ONO EYES-See Below&Pg.3
<br /> El Pursuant to RCW 10.28.261,property owners and leaseholders cannot perform electrical work on bulldings fo rent,sale,or lease
<br /> tti•,thout the proper electrical licensing and certification,or exemption.By checking this box,I am stating that I have completed and
<br /> signed Iho AFFIDAVIT on pago 3 of this application to receive an exemption from this licensing/certification requirement.
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<br /> OWNERNAME: 1 L tCn� TENANT
<br /> /nBUSINESS NAME If Commercial :
<br /> OWNER MAILING ADDRESS: STREET ' FijnSj I'T"'Y . 1 A /�1
<br /> My `v � �G �� STATE �/v-J� ZIP 2 v1
<br /> 0141!:£R PHONE: OWNER EMAIL: �Q1 R Q Dc Yl'�C�ll •C w1
<br /> C014TRACTOR NAME:
<br /> CONTRACTOR ADDRESS: SIREET
<br /> CITY STATE ZIP
<br /> C014TRACTOR PHONE: CONTRACTOR EMAIL:
<br /> CONTRACTOR LIC.a(REQUIRED): CITY OF EVERETT BUSINESS LIC, REQUIRED):
<br /> PRIMARY CONTACT: 0 OWNER 0 CONTRACTOR ❑OTHER(Please Specify)
<br /> CONTACT NAME: CONTACT PHONE: 2 1. 6501
<br /> CONTACT EMAIL: 9 runt l • co M
<br /> AGAr I Ml I;I I l,c+tb/Lort'lj 01at i/to ru rood and otamlnad this application and know rho samo to be Ituo and cormcl. Ail prolis ons of laws and oidinancos govroming this
<br /> to vet P:crcd.Ihoutor apauhdd hoto4r or net Iho gtonrrna of a permit daus not prosumo to glue aulhotfty to violate or concol tho provisions of any other stato or
<br /> low I.V'0ultAn w U.e f+n,ar,cu cl ccn>fruerian. Ihil 1 mm Authorrrud by tho ownur o/this properly to patfoml tho wwh for Irhkh ap#lcollon!s mado and 1
<br /> Me 'era Gytrrouas 1 r IU?rr GV/end 199 7tx]NMC. City of Evorett official Use Only
<br /> PERMIT tt:
<br /> 201,"1 E 6) q09-06c
<br /> OmmlAuutorttt+d Apunt Slg4atuls Dale (Ravisod71,7022) Pago 1-Application
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